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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803796
Report Date: 12/20/2023
Date Signed: 12/20/2023 06:15:01 PM


Document Has Been Signed on 12/20/2023 06:15 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:WILLOW GLEN HOMEFACILITY NUMBER:
496803796
ADMINISTRATOR:FLORES INEZ M.FACILITY TYPE:
740
ADDRESS:4750 COUNTRY CLUB DRTELEPHONE:
(707) 708-2199
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 6DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Zoe Teeter-AdministratorTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Dina Alviso conducted Required 1-Year inspection and met with Licensee Zoe Teeter and Administrator Inez Flores. Staff had contacted Licensee and notified them of LPA's arrival.

LPA reviewed six (6) resident files. LPA reviewed six (6) staff files. All staff had criminal record clearance as required. All staff had current First Aid and CPR certifications. All staff had required annual training.

Hot water was checked at 112.7 degrees Farenheight. The facility and resident rooms were clean and orderly. All common areas, hallways, resident rooms, and bathrooms had sufficient lighting. All bathrooms had grab bars, and non-slip flooring/mats for resident use as needed. Medications were stored as required, all medications were centrally stored. All toxins/cleaners were locked and inaccessible as required. Facility had a sufficient supply of food, hygiene products, and paper products. The facility has an emergency supply of food, water, and other emergency items to meet the required 72 hour for sheltering in place supplies. All exits were unobstructed. All exits had working auditory alarms. Emergency drills are conducted as required, the last fire drill was conducted 11/8/23.

The following documents were requested to be updated and submitted by 1/20/24.

Liability Insurance
Personnel Report
Administrator Certificate
Client Roster
Emergency Disaster Plan-If any changes, please submit new copy-if no changes, sign & date-submit last page.
Infection Control Plan-If any changes, please submit new copy-if no changes, sign & date-submit last page.

No deficiencies cited during this inspection
Exit interview conducted with licensee and a copy of the report printed for the facility.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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