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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803915
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:47:27 PM


Document Has Been Signed on 07/23/2024 04:47 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:MARIE'S CARE HOMEFACILITY NUMBER:
496803915
ADMINISTRATOR:BISCOCHO, LIZAFACILITY TYPE:
740
ADDRESS:7334 CARIOCA CT.TELEPHONE:
(707) 794-0591
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 5DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Liza Biscocho-Licensee/AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit and met with Licensee/ Administrator Liza Biscocho. LPA observed two (2) caregivers on duty, Charles and Jittraporn (Nettie). Facility has five (5) residents in care; One (1) resident is receiving hospice services.
Facility has an approved hospice waiver for three (3) residents. Facility has an approved dementia plan of operation. Facility has an emergency disaster and evacuation plan as required. Facility has an infection control plan as required. Fire clearance is approved for six (6) non-ambulatory, of which one(1) may be bedridden. LPA reviewed five (5) resident files. Medication records and storage of medications were checked. All medications were locked and inaccessible to residents in care. LPA reviewed three (3) staff files. All staff have required criminal record clearance. Staff have required training. Staff have first aid certification and cpr certification as required. Facility has emergency drills quarterly as required, per record reviews.
LPA toured the facility with Administrator. Hot water was checked at 110. degrees Fahrenheit. All exits were free and clear of obstruction. All exit doors had auditory alarms. Fire extinguishers, two (2), were showing fully charged, were inspected and tagged. Smoke alarms are hard wired, and is also a carbon monoxide detector. Food supply was sufficient. All medications were locked and inaccessible to residents in care. All cleaners/disinfectants were locked and inaccessible to residents in care. Facility was clean and orderly. Facility had a sufficient supply of personal protective equipment (PPE), paper products, hygiene products, linens, and furnishings for resident use.
LPA is requesting the following documents be updated and submitted by 8/23/24:
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required- if no changes submit last page with date/signature of review)
Infection Control Plan (ensure to review and update as needed/required- if no changes submit last page with date/signature of review)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster

No deficiencies cited today.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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