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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803654
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:09:49 PM

Document Has Been Signed on 11/18/2024 12:09 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:HARSTAD HOUSEFACILITY NUMBER:
496803654
ADMINISTRATOR/
DIRECTOR:
PICKERING, ELIZABETHFACILITY TYPE:
772
ADDRESS:1120 GORDON LANETELEPHONE:
(707) 527-3249
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 10CENSUS: 7DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Laurel Anderson, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct an Annual Required inspection and met with Program Director (PD), Laurel Anderson. Administrator Elizabeth Pickering arrived later.


At approximately 10:00am LPA and PD toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured at 105.1, 110.7, and 112.7 degrees F which is within the allowable range of 105 to 120 degrees F. Medications were centrally stored and locked.

Fire extinguishers were last inspected 9/9/2024. Facility's fire system is maintained by a vendor and the most recent test/service of the system was conducted April 2024. Smoke detector/Carbon Monoxide detector was tested and operational during inspection. Most recent fire/disaster drill was conducted 11/12/2024.

Five staff files and five client files were reviewed. Documentation present.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report

No deficiencies cited during this inspection
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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