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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:37:59 PM


Document Has Been Signed on 03/23/2023 02:37 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
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:
(707) 508-7634
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Aira Monte, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required inspection and met with Administrator, Aira Monte. There is a total of 6 residents, 2 under hospice care.

Upon arrival, LPA observed that staff continue to wear masks per current guidance. LPA initiated a tour of the facility at approximately 9:15 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms measured at 110.8 , 112.6, and 113.3 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation.

Fire extinguisher was last inspected February 20, 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational.

Five staff five resident files were reviewed. All staff reviewed has current CPR and 1st Aid training Certification.Administrator Certificate for Administrator Aira Melanie U Monte 6056005740 expires 08/29/2024. Medications and medication records were reviewed.

Administrator and lPA discussed their Emergency Disaster Plan and Infection Control Plan.

There were no deficiencies cited at this time.

Continue on LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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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: 03/23/2023
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Licensee/Administrator to submit updates of the following documents by 4/13/2023 to SRRO:
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facilities Residents
Infection Control Plan (If changes)
Current Administrators Certificate
Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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