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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803849
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:01:58 PM


Document Has Been Signed on 07/07/2023 03:01 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:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Eva KarikariTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Adom Manor Care Home for the purpose of conducting a Required 1 year inspection. LPA was greeted outside by Administrator, Eva Karikari and was granted access into the facility.

LPA and the Licensee toured the 1 story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on May 2023 at the time of the inspection. First Aid kit was fully stocked and appropriate during the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in 3 of 3 resident bathrooms measured at 119 degrees and is within acceptable range of 105 to 120 degrees F. Staff Water temperature measured at 119 degrees in 1 of 1 staff bathroom, and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Food menu was observed during the inspection. Activities Menu was observed during the inspection. There are special provisions made for individuals with special dietary needs. Medications were centrally stored and locked. Medication Orders were reviewed and found to be appropriate during the Required 1 year inspection. Cleaning products and other toxins are located in the garage that was locked and inaccessible to residents in care at the time of the inspection. Emergency Generator was also located in the garage. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

(Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496803849
VISIT DATE: 07/07/2023
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5 of 5 Resident records were reviewed and found to be appropriate during the Required 1 year inspection. 3 of 3 staff records were reviewed and found to be appropriate during the Required 1 year inspection. First Aid/CPR was valid for all staff members that provide Care and Supervision to residents in care.

Infection control plan, Emergency Disaster Plan, Staff and Resident interviews will be conducted at a later date and time.

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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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