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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803576
Report Date: 10/16/2024
Date Signed: 10/16/2024 05:22:08 PM


Document Has Been Signed on 10/16/2024 05:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SLEEPY HOLLOW ASSISTED LIVINGFACILITY NUMBER:
496803576
ADMINISTRATOR:ARTHUR ALCONESFACILITY TYPE:
740
ADDRESS:3707 SLEEPY HOLLOW DRIVETELEPHONE:
(707) 953-2161
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 5DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Arthur Alcones-AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required- 1 Year inspection and was greeted by staff. Staff contacted Licensee/Administrator Arthur Alcones to notify them of the LPAs arrival. Administrator Arthur arrived to meet with the LPA.

Fire clearance approval for six (6) non-ambulatory, of which one (1) may be bedridden. The facility has a required infection control plan. The facility has a required emergency disaster plan as required. Facility has an approved dementia plan.

The LPA toured the facility with staff. All exits were observed to be clear and unobstructed. The facility has sufficient lighting in common areas and resident rooms.

The LPA discussed some concerns of the flooring and rugs in the facility; Administrator stated to the LPA that they were having some of the rooms flooring changed out soon, and is also renovating the kitchen area soon.

This annual will be completed by the LPA at a later date.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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