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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804104
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:10:37 AM

Document Has Been Signed on 08/28/2023 11:10 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:LOLA MANORFACILITY NUMBER:
496804104
ADMINISTRATOR:ALLI, STANLEYFACILITY TYPE:
735
ADDRESS:6704 STURTEVANT DRIVETELEPHONE:
(707) 303-7922
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 4CENSUS: 4DATE:
08/28/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator/Licensee, Lola AlliTIME COMPLETED:
11:20 AM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Post-Licensing Visit and met with Staff Members, Godfrey Okoro, and Jocelyn Valce. Administrator/Licensee, Lola and Stanley Alli, arrived at approximately 9:35AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Non-Ambulatory Clients. Upon arrival, LPA was informed that there were 4 clients in care and 3 staff members on-site.

At approximately 9:15AM, LPA reviewed Facility staff roster. During Review, LPA found that Staff Member 1 (S1) was fingerprint cleared, but not associated to the facility as required. LPA contacted the Regional Office and confirmed the fingerprint clearance and association status of S1 to the facility. Administrator/Licensee immediately accessed the Guardian Background Clearance website and ensured that S1 was associated to the facility as needed.

**Administrator/Licensee understands that a Civil Penalty is not being issued today for S1 since LPA observed S1 be associated to the Facility while on-site.**

At approximately 9:50AM, LPA conducted a walk-though of the facility with Administrator/Licensee. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with four single client bedrooms, an office, two bathrooms and common areas. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Medications were observed to be locked the facility's medication cart.

At approximately 10:25AM, LPA reviewed staff files and found that staff on-site had current first aid certificates. At approximately 10:40AM, LPA reviewed client files, medication records, and P&I monies. Client files were found to be well organized, thorough and contained the required documentation. Medication were centrally stored and secure. P&I Monies were found to be documented, secure and not commingled.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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: LOLA MANOR
FACILITY NUMBER: 496804104
VISIT DATE: 08/28/2023
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Continued from LIC809

Facility's fire extinguishers were recently purchased. Facility's combination smoke and carbon monoxide detectors were tested and operational.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator/Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
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