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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 12/17/2024
Date Signed: 12/17/2024 12:55:15 PM

Document Has Been Signed on 12/17/2024 12:55 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:CALIFORNIA MENTOR-CALISTOGA HOMEFACILITY NUMBER:
496803832
ADMINISTRATOR/
DIRECTOR:
SARAH LUCASFACILITY TYPE:
735
ADDRESS:5302 BADGER RDTELEPHONE:
(707) 538-9684
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Sarah Lucas was not available to come to the facility but gave caregiver permission to sign.

At approximately 9:30am LPA 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 night stand and chest of drawers. All bedrooms need a lamp. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 110.3 degrees F in the bath by the living room, 111.2 degrees F in the main bath, 109.3 degrees F in room #3 which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 10/23/2023, but are showing as fully charged. Smoke/Carbon Monoxide detectors located throughout the facility are serviced by a vendor, last date of service was January 2024. Facility last disaster drill was conducted 9/27/24.

At approximately 11:00am LPA conducted a review of 3 resident records. Doctor orders and CCL exceptions on file. At approximately 11:30am LPA conducted review of 5 staff records. All staff have their current CPR on file.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CALIFORNIA MENTOR-CALISTOGA HOME
FACILITY NUMBER: 496803832
VISIT DATE: 12/17/2024
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At approximately 12:00pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

At approximately 12:45pm LPA and caregiver conducted check of P&I. All records present and cash is reconciled.

Sarah Lucas Administrator Certificate 6060043735 expires 6/23/25. LPA and caregiver discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

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
LIC308- Designation of Responsibility

No deficiencies cited.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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