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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803627
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:24:12 PM

Document Has Been Signed on 09/22/2022 02:24 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Jennica NarcisoTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Jennica Narciso arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff and asked to sign in and complete a questionnaire with standard Covid-19 screening questions. LPA confirmed with Administrator that facility was conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 1:15pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected once per shift. Facility continues to screen clients for Covid-19 daily and maintain documentation.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and Personal Protective Equipment (PPE). LPA and Administrator discussed visitation and activities.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NARASOL HOME
FACILITY NUMBER: 496803627
VISIT DATE: 09/22/2022
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Continued from LIC809

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gloves, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced August 2022. Facility has a fire system that includes carbon monoxide detectors that is maintained by a vendor. The most recent testing and service was conducted August 2022.

Administrator and LPA discussed their Emergency Disaster Plan.



Administrator to submit updates of the following documents by 10/22/2022:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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