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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803828
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:34:28 PM


Document Has Been Signed on 07/20/2023 03:34 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:RINCON VALLEY GUEST HOMEFACILITY NUMBER:
496803828
ADMINISTRATOR:POPAT, SABRINAFACILITY TYPE:
740
ADDRESS:996 ESTES DRTELEPHONE:
(707) 539-6247
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 1DATE:
07/20/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator, Martha Marimbi
Licensee/Administrator, Fikre Gurja		TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rincon Valley Guest Home for the purpose of conducting a Case Management-Annual Continuation Inspection. LPA was greeted at the door by Assistant Administrator, Martha Marimbi and Licensee/Administrator, Fikre Gurja and was granted access into the facility.

During the Case Management-Annual Continuation, LPA reviewed 4 of 4 staff files and found those files to be appropriate during the Required 1 year inspection. LPA reviewed 2 of 2 resident records and found those to be appropriate during the inspection. 1 of 1 Medication Orders were reviewed with the Licensee. LPA interviewed 4 of 4 staff members. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Licensee/Administrator in detail. LPA discussed the Emergency Disaster Plan. However, LPA observed on July 17, 2023 that the facility does have an Emergency Generator and the house is Solar Powered. LPA advised to update the Emergency Disaster Plan to reflect that. LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Liability insurance
Control of Property
Resident Roster

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Licensee/Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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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