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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803849
Report Date: 03/15/2022
Date Signed: 03/15/2022 03:08:17 PM


Document Has Been Signed on 03/15/2022 03:08 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:ADOM MANOR CARE HOMEFACILITY NUMBER:
496803849
ADMINISTRATOR:KARIKARI, EVAFACILITY TYPE:
740
ADDRESS:2543 TACHEVAH DRTELEPHONE:
(707) 526-6895
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 5DATE:
03/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee/Administrator, Eva KarikariTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 3/15/2022 at approximately 2:20 PM to conduct a case management inspection regarding an incident report received by community care licensing on 2/11/2022. LPA met with licensee/administrator, Eva Karikari.

Incident report indicated that resident had been skipping meals. Resident was vomiting on 2/8/2022 and refusing care. Resident was monitored throughout the day. Primary care physician was notified but did not respond to facility's call. EMT was called that night and resident was taken to the hospital.

LPA reviewed discharge paperwork. Resident was in the hospital for 4 days with a diagnosis of esophagitis. Administrator indicated resident has returned to baseline and is now doing well.

Exit interview conducted with administrator and a copy of this report left for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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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