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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803759
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:20:35 PM


Document Has Been Signed on 06/22/2023 03:20 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:NATASHA'S HOMEFACILITY NUMBER:
496803759
ADMINISTRATOR:GLENN VARGASFACILITY TYPE:
740
ADDRESS:3365 PETALUMA HILL RDTELEPHONE:
(650) 270-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:3CENSUS: 3DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Glenn VargasTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Glenn Vargas.

LPA initiated a tour of the facility around 2:40pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. 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. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment.
Fire extinguisher was purchased April 2023 and is not yet due for servicing. Facility water is not reaching the temperature needed for sanitation. LPA has requested that Administrator provide an update within 24 hours that outlines a plan on how dishes will be sanitized until water reaches the required level for sanitation and how facility will ensure proper hygiene for clients and staff until the issue is resolved.

Four resident files were reviewed. Administrator Certificate for Administrator Glenn Varagas 6026688740 expires 8/17/2023.

LPA was unable to complete inspection so will return.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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