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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803627
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:04:38 PM

Document Has Been Signed on 09/07/2023 04:04 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:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Administrator, Jennica (Abby) NarcisoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPAs) Victoria Bertozzi and Christi Coppo arrived unannounced to conduct an Annual Required inspection and met with Administrator, Jennica (Abby) Narciso.

Upon arrival, LPAs observed that staff and visitors are required to wear masks and temperature taken at entry. LPA initiated a tour of the facility around 1:10pm and made the following observations: Facility was at a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature measured at 114 and 115 degrees F, in respective bathrooms which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Additional cleaning supplies and disinfectants are stored in cabinets with the ability to be locked and inaccessible to residents located in garage. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility has a back-up generator in case of power failure. Emergency food and water supplies were stored in garage.

Fire extinguisher was last inspected July 2023. Facility has hardwired combination Smoke/Carbon Monoxide detectors located throughout the facility that were being serviced during inspection. Most recent fire drill was conducted August 7, 2023 and the disaster drill conducted August 14, 2023.

Four staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Jennica Narciso 6018481735 expires 6/29/2024. Medications and medication records were reviewed. Client cash resources were also reviewed. LPAs conducted staff interviews but were unable to conduct interview with clients as they are non-verbal.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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: 09/07/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 10/07/2023:


LIC 500 Personnel Summary
Surety Bond
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

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

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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