<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:53:06 AM


Document Has Been Signed on 04/14/2022 11:53 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:ALTA CARE HOMEFACILITY NUMBER:
496804055
ADMINISTRATOR:MONTE, AIRA MELANIE V.FACILITY TYPE:
740
ADDRESS:96 ALTA DRIVETELEPHONE:
7075087634
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 0DATE:
04/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Laarni & Dave Lockerbie and Administrator Aira Melanie MonteTIME COMPLETED:
11:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hansen conducted a pre-licensing inspection and met with Licensee Laarni & Dave Lockerbie & Administrator Aira Melanie Monte. Fire clearance has been approved for 6 nonambulatory residents by the Petaluma Fire Department. LPA will conduct a component III orientation with Licensee/Administrator’s Laarni & Dave Lockerbie/Aira Melanie Monte. Facility has a dementia care program and a request for hospice waiver for 2.

LPA toured facility and observed: Facility is a one floor residence in good repair and at a comfortable temperature. Hot water temperature checked 111.7 degrees F to 114.4 degrees F in resident's bathrooms as required by Title 22 Regulations and Fire Extinguisher was last checked on 1/26/2022. The facility has a phone line designated for resident’s use. There is an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cookware. Personnel and residents' records will be stored in locked office desk in middle of facility-living room. Locked cabinets above office wall will contain centrally stored medications. Facility plans on having awake staff. Licensee’s rent back adjacent home at 98 Alta Dr. for easy access.

The facility has five resident’s bedrooms, one of which is shared, three bathrooms (one staffs) facility has a kitchen, laundry room in garage, living room area, office, and dining room. Facility plans on having several different activities available for residents as desired. There is outdoor porch space for activities and visiting. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked. Postings noted to be current and in compliance with guidelines. Locked cabinets for sharps in kitchen and cleaning/laundry supplies in locked cabinet in garage. First aid kit was observed. Emergency supplies located in the office and PPE cabinet observed in front hallway credenza. All exits have egress alarms. Mitigation Plan has been approved 4/11/2022.

Continue on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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: ALTA CARE HOME
FACILITY NUMBER: 496804055
VISIT DATE: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facilities back bedroom exit #3 has small wooden deck out the sliding glass door needing to step down and around the corner needing to step up again to exit property (pics LIC 812). Licensee will put ramps in both locations and send to LPA prior to accepting residents.

Facility is cleared for licensure.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2