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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804039
Report Date: 05/13/2022
Date Signed: 05/13/2022 11:03:01 AM


Document Has Been Signed on 05/13/2022 11:03 AM - 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:WILLOW GLENFACILITY NUMBER:
496804039
ADMINISTRATOR:TEETER, ZOEFACILITY TYPE:
740
ADDRESS:2540 SUMMERFIELD ROADTELEPHONE:
(707) 479-5577
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 4DATE:
05/13/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Admin, Zoe Teeter/Maria Ines FloresTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 05/13/2022 to conduct a post licensing inspection. LPA was initially greeted by staff who screened LPA for COVID symptoms and asked LPA to sign in. LPA met with licensee and administrator, Zoe Teeter and Maria Ines Flores. Currently there are 4 residents in care, one who is on hospice and some who have a diagnosis of dementia. LPA observed auditory devices functioning on the front door and on the doors exiting to the backyard.

The amount of fresh and nonperishable foods appeared to be within regulation. LPA observed non perishable food in kitchen cabinets. Toxins are secured and inaccessible under locked sink cabinets. Medications are locked and centrally located in medication closet. LPA recorded a water temperature of 110.6 and 119.1 degrees F which is within regulation of 105 to 120 degrees F at faucets accessible to residents. Food is available for residents any time of the day. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. Fire extinguisher inspected was charged and dated 04/19/2022. Smoke detectors and carbon monoxide detector were operational,. LPA observed required CCL Complaint poster in addition to COVID-19 postings. Facility to add LTCO posting. Facility is screening visitors at the front door which includes taking temperatures and requiring visitors to wear masks.

LPA reviewed 4 out of 4 resident files. LPA observed current physician's reports, appraisals, and admission agreements. LPA reviewed 3 out of 6 staff files. 3 out of 3 reviewed staff files had current CPR/First Aid training. LPA also observed documentation of required training for care giving staff. Disaster drills are conducted quarterly.

Facility to submit application to assign new administrator.

No deficiencies observed during today's inspection. Exit interview conducted with licensee and administrator. LPA was unable to print the report. LPA emailed the report to the facility during the visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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