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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803627
Report Date: 10/15/2024
Date Signed: 10/15/2024 01:24:11 PM

Document Has Been Signed on 10/15/2024 01:24 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/
DIRECTOR:		NARCISO, JENNICA AFACILITY TYPE:
734
ADDRESS:2175 GROSSE AVETELEPHONE:
(510) 331-9139
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 5CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Jennica (Abby) Narcisso-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required - 1 Year inspection and was greeted by staff Ronaldo Jimenez; Nurse on duty was Eliseo (Eli) Valenzuela. LPA observed three other caregivers on duty. Administrator, Jennica Narciso was contacted by staff and will be arriving to meet with the LPA.

There are four (4) clients in care; Three (3) clients were attending day program during the LPA's inspection.
Facility has a fire clearance approval for five (5) non-ambulatory, of which five (5) may be bedridden. Facility has a required emergency disaster plan. Per review of records, last fire/disaster drill was a wild fire drill conducted on 9/10/24, and a fire drill on 9/20/24.

LPA reviewed four (4) client files. All client files were complete. P&I funds were accounted for, and maintained in compliance with regulations.
LPA reviewed five (4) staff files. All staff files were complete. All staff had required training, required criminal record clearance, current certification in first aid and CPR.

Facility hot water was checked at 116. degrees Fahrenheit. All exits were free and clear of obstruction. All medications were locked up and inaccessible to clients, and all others that don't handle client medications. All disinfectants/cleaners were locked up and inaccessible to clients in care. The facility was observed to be clean and orderly. All resident rooms, hallways, bathrooms, and common areas had sufficient lighting for clients in care. Bathrooms were clean, and equipped to meet hygiene needs for clients in care. Food supply was observed to be sufficient. Sufficient supply observed regarding, hygiene supplies, linens, personal protective equipment (PPE), paper products, and disinfectants/cleaners. Backyard was observed to be clean and orderly, with fire exit free and clear of obstruction.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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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: 10/15/2024
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The facility has two large outside generators in the backyard; These generators are inspected every three months to ensure they are working properly. The front of the facility's cement patio pathways were observed to be free and clear of any obstructions; This area has patio furnishings for client, staff, and visitors use as needed. Facility has smoke alarms that are also carbon monoxide detectors; The facility is fire sprinkled. Fire extinguishers, five (5), were all serviced as required.

LPA requested the following updated documents by 11/15/24:
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Surety Bond-amount per LIC400
Emergency Disaster Plan- if any changes, submit a copy- if no changes, please sign and date and submit copy (last page)
Register of residents
Facility's liability Insurance if obtained

There were no deficiencies cited during today's inspection.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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