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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803630
Report Date: 12/22/2022
Date Signed: 12/22/2022 04:06:50 PM

Document Has Been Signed on 12/22/2022 04:06 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jennie Manganaan-LVNTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required 1Year inspection, on 12/22/2022 at approximately 2:10pm, and met with LVN Jennie Manganaan; LPA observed three additional staff/caregivers on duty during the inspection. LVN Jennie contacted the Administrator, RN Abbie Narciso, to notify them of LPA's arrival to the facility. The Administrator had Lead Staff House Manager Fely Juanson meet the LPA at the facility.

This inspection will focus on the infection control procedures and practises of this facility.

Staff screened the LPA upon their arrival to the facility. Sanitizer was available on the screening entry table. LPA observed all staff to be wearing masks as required. The facility has a sufficient supply of PPE.

Facility is fire cleared for five(5) clients that are nonambulatory, of which five(5) may be bedridden. The facility was clean and orderly. The facility was observed to be at a comfortable temperature.

The fire extinguisher(s) was serviced and tagged as required- dated 8/29/2022. The facility has a sufficient supply of food, water supplies, 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.
Exit interview conducted with Fely Juanson, Lead House Manager.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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