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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803654
Report Date: 10/22/2021
Date Signed: 10/22/2021 12:47:03 PM

Document Has Been Signed on 10/22/2021 12:47 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:HARSTAD HOUSEFACILITY NUMBER:
496803654
ADMINISTRATOR:LAND, AUDREYFACILITY TYPE:
772
ADDRESS:1120 GORDON LANETELEPHONE:
(707) 527-3249
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 10CENSUS: 8DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Administrator, Audrey LandTIME COMPLETED:
12:56 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and was greeted by Administrator, Audrey Land. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that the facility has Covid related posters on the exterior door. LPA's temperature was checked upon entry to the facility. LPA was asked to complete sign in sheet that documented visitor temperature and asked standard Covid-19 questions. LPA conducted a walk-through of the facility and observed hand washing signs in restrooms. LPA suggested that facility add some cough etiquette and social distancing posters throughout the facility. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed in a centralized space in the facility and in the office area of the facility. Hand sanitizer is not kept in client rooms to ensure the safety of clients in care. Clients are encouraged to wear masks and staff are required to wear masks while in the facility. Observed staff had masks on during this visit.

LPA and Administrator discussed client activities and visitation. Facility has a designated visitation area both inside and outside. Facility has had a recent fire inspection and not issues were noted.

Caregivers have completed Personal Protective Equipment (PPE) training but have not been N-95 Fit tested. Commonly touched surfaces are disinfected at least once per shift.

Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is accessible to staff who need it. Facility maintains a 30 day supply of medication.

LPA confirmed that facility is following CCL guidance for visitation and testing.

Administrator and LPA discussed their Emergency Disaster Plan.



No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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