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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803630
Report Date: 12/06/2021
Date Signed: 12/06/2021 03:10:58 PM

Document Has Been Signed on 12/06/2021 03:10 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:PETERSON LANE HOMEFACILITY NUMBER:
496803630
ADMINISTRATOR:NARCISO, JENNICA AFACILITY TYPE:
734
ADDRESS:1618 PETERSON LANETELEPHONE:
(707) 978-2573
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 5CENSUS: 5DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennica Narciso-AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Alviso conducted a 1 Year Required inspection, on 12/6/21 at approximately 12:00pm, and met with Administrator Jennica "Abbie" Narciso. There were also three caregivers on duty during the inspection.

This inspection will focus on the infection control procedures of this facility. Administrator stated that the facility is in compliance with the Departments PIN 21-44.

The LPA was screened in the entry when entering the facility, temperature was taken, and covid questions were asked. Sanitizer was available on the screening entry table. LPA observed all staff to be wearing masks as required. The facility has a large PPE supply that was observed by the LPA to be stored in the garage.

Facility is fire cleared for five(5) clients that are nonambulatory, this includes approval for five (5) bedridden approval, not to exceed a capacity total of five clients in care. The facility had all exits unobstructed. The facility was clean and orderly. The facility was observed to be at a comfortable temperature.

The Santa Rosa Fire Department was out August 20, 2021, the fire extinguishers, sprinkler system, smoke alarms with carbon monoxide detector were all inspected and found to be working appropriately. The facility has a sufficient supply of food, water supplies, and hygiene supplies, paper products, and cleaning supplies. The facility has sufficient furnishings for use by all clients in care, staff, and visitors.

There are no deficiencies cited today.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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