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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804039
Report Date: 02/07/2022
Date Signed: 02/07/2022 01:59:33 PM

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:WILLOW GLENFACILITY NUMBER:
496804039
ADMINISTRATOR:TEETER, ZOEFACILITY TYPE:
740
ADDRESS:2540 SUMMERFIELD ROADTELEPHONE:
(707) 479-5577
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 0DATE:
02/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Zoe Teeter-Applicant/LicenseeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection and met with applicant Zoe Teeter, and Gina Hunter who will be the facility Administrator once the application is approved for licensure.

Gina Hunter's administrator certificate #6055501740 is current and expires 3/11/22.

Facility has a fire clearance approval by the Santa Rosa Fire Department for a total of six non-ambulatory, which includes one bedridden-effective 1/20/2022. Facility has an approved dementia plan, and a hospice approval for three(3) residents.

Facility will operate with an awake night staff and Licensee will ensure sufficient staffing at all times.

Hot water was checked at 113.F which is within regulation. All exits were unobstructed in the home. All utilities were on and operational. All bathrooms had grab bars, and mats for the shower/bath flooring for resident use.

There are 13 smoke alarms, that are also carbon monoxide detectors, all were working appropriately during the inspection. Fire extinguishers, two (2) are fully charged as required.

LPA observed the large backyard area that has an enclosed courtyard area; Beyond the courtyard area is more land and a creek. Applicant will ensure the courtyard is made secure and healthy and safe for resident use. There are two gates in the courtyard, one leads to an exit out of the facility from the backyard area but the gate is very narrow and will not fit a wheelchair or possibly walkers, easily and/or safely for residents in an emergency.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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 2
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: WILLOW GLEN
FACILITY NUMBER: 496804039
VISIT DATE: 02/07/2022
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The cement on the outside area as you walk through the gate is very uneven, and cracked, this needs to be repaired to ensure health and safety when used in an emergency.

LPA observed some other items needing to be completed in regards to finish/touch-up in rooms and bathrooms that are almost completed.

LPA completed Component III with applicant Zoe Teeter, and the hired Administrator Gina Hunter.

Once the items discussed and mentioned by the LPA in the report are complete, the applicant Zoe Teeter, will contact the analyst to schedule a return to continue the pre-licensing inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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