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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:22:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:FLORES, MARIAFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 17DATE:
07/22/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Maria FloresTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted an unannounced POST licensing inspection of this licensed senior care facility and was greeted by administrator Maria (Ines) Flores. LPA toured the building and grounds which were found to be clean and in good repair. There are currently 17 residents in care. All walkways and exits were observed to be unobstructed.

The amount of fresh and nonperishable foods is within regulation. Toxins are stored and inaccessible to residents in care. Water temperature measured at 113.3 and 114.0 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected was charged dated 08/13/2020. LPA was provided with invoice from third party company responsible for inspecting fire safety system which includes smoke detectors and sprinkler system dated November 10, 2020. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings.

While at the facility LPA followed up with previously reported incident. LPA examined the locking door knob of R1 (pictures taken). R1 is able to lock/unlock the door from the inside and is allowed to have a key if she wishes.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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