<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803627
Report Date: 09/23/2021
Date Signed: 09/23/2021 12:24:00 PM

Document Has Been Signed on 09/23/2021 12:24 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:NARASOL HOMEFACILITY NUMBER:
496803627
ADMINISTRATOR:NARCISO, JENNICA AFACILITY TYPE:
734
ADDRESS:2175 GROSSE AVETELEPHONE:
(510) 305-8919
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 5CENSUS: 5DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Jennica NarcisoTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required -1 Year inspection at approximately 11:15 AM, and was greeted by staff. Administrator arrived shortly thereafter. The inspection was focused on the infection control procedures and practices of the facility.

Upon entry LPA was asked for proof of vaccination and screened for COVID symptoms. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan was submitted by administrator and approved by Community Care Licensing (CCL).

The facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through local public health. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Client bedrooms are single occupancy therefore clients could isolate in their own bedrooms if necessary. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation and provided guidance to contact regional office if facility were to need more.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinet. A 30 day supply of medications are stored in a locked cabinet which is located in nursing station, making them inaccessible to residents. The facility has a sufficient supply of PPE and hygiene supplies located in the garage. Facility is no longer conducting surveillance testing. All staff are vaccinated and all residents are vaccinated.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: NARASOL HOME
FACILITY NUMBER: 496803627
VISIT DATE: 09/23/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Clients have meals primarily in their individual bedrooms. LPA and administrator discussed resident activities which include barbecues on the outdoor patio area. Family is allowed to visit indoors.

LPA requested the following documents during the visit:

LIC 308
LIC 500
LIC 610D
LIC 9020
Admin Certificate
Liability Insurance

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2