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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804104
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:58:24 PM

Document Has Been Signed on 05/19/2023 02:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LOLA MANORFACILITY NUMBER:
496804104
ADMINISTRATOR:ALLI, STANLEYFACILITY TYPE:
735
ADDRESS:6704 STURTEVANT DRIVETELEPHONE:
(707) 303-7922
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 4CENSUS: 0DATE:
05/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicants, Lola and Stanley AlliTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Pre-Licensing Inspection and met with Licensees, Lola and Stanley Alli.

Applicant has applied for a Change of Location for an existing facility. LPA initiated a tour of the facility at approximately 2:00pm and made the following observations: Facility is a one story residence with four single client bedrooms, an office, two bathrooms and common areas. Passageways were free from obstruction. All client rooms are furnished per regulation. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathroom read at 105 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Facility backyard has an area for visiting and activities.

Facility received an approved fire clearance dated April 27, 2023 that allows for four non-ambulatory clients. Fire Extinguishers are new and are net yet due for servicing. Facility has combination Smoke/Carbon Monoxide detectors that were tested as part of the fire inspection. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Emergency food and water supplies are stored in the garage and pantry. Medications are secured in a medication cart and files are located in a locked cabinet.

LPA observed required postings including the CCL Complaint Poster and Personal Rights for Individuals with Developmental Disabilities.

Component III was waived.

No issues noted. LPA will contact the Central Applications Unit so that they move forward with process.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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