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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803654
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:37:55 AM

Document Has Been Signed on 10/23/2023 11:37 AM - 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:HARSTAD HOUSEFACILITY NUMBER:
496803654
ADMINISTRATOR:HERNANDEZ, ELIZABETHFACILITY TYPE:
772
ADDRESS:1120 GORDON LANETELEPHONE:
(707) 527-3249
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 10CENSUS: 9DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Program Director, Kimmie.TIME COMPLETED:
11:47 AM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Program Director, Kimmie Kennedy. Program Director was unable to stay for entire visit so gave Assistant Director Sarah Magnani permission to sign report.

Upon arrival LPA observed a posted Visitation Policy on the front door. LPA confirmed with staff that the poster no longer reflected the facility's visitation policy. LPA requested that poster be removed. LPA initiated a tour of the facility around 9:10am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. LPA was unable to test water during inspection. Extra hygiene products and linens were available. 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.

Fire extinguisher was last inspected August 2023. Facility's fire system is maintained by a vendor and the most recent test/service of the system was conducted May 2023. Carbon Monoxide detector was tested and operational during inspection. Most recent fire/disaster drill was conducted 9/2023.

Six staff files and five client files were reviewed. Staff have required training.

Licensee/Administrator to submit updates of the following documents by 11/23/2023:
LIC 500 Personnel Summary
LIC308 Designation of Responsibility (If applicable)
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: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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