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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:25:57 AM


Document Has Been Signed on 08/03/2023 10:25 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:
(707) 508-7634
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
08/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Laarni Lockerbie, LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Case Management inspection to this facility and met with Laarni Lockerbie, Licensee who arrived at 8:45 AM. The purpose of today’s inspection is to amend LIC 9099/9099C from delivering Complaint findings on 7/18/2023. LPA arrived at facility to obtain signatures for amended complaint findings from 7/18/2023 due to Technical Violation not being related to complaint.

On 7/18/2023 LPA was at facility delivering complaint findings and observed Licensee putting 24 hour container of entire day's medication pre-poured for each resident away in locked medication cabinet. LPA discussed regulation to not pre-poured or transferred from original container into any other container. Technical Violation given CCR 87465(h)(5)(see LIC9102).

See Amended 9099/9099-C from Complaint investigation 7/18/2023

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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