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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804104
Report Date: 05/01/2024
Date Signed: 05/01/2024 03:51:49 PM

Document Has Been Signed on 05/01/2024 03:51 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/
DIRECTOR:
ALLI, STANLEYFACILITY TYPE:
735
ADDRESS:6704 STURTEVANT DRIVETELEPHONE:
(707) 303-7922
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 4CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Licensee, Lola Alli and Administrator, Stanley Alli TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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 Analysts (LPA) Helena Rummonds and Jacky Macias arrived unannounced at approximately 1:20 PM to conduct an Annual Required inspection and was greeted by Staff. LPAs and staff discussed the purpose of the visit. Licensee Lola Alli arrived shortly after.

LPA and Staff initiated a tour of the facility around 1:30 PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 109 and 110 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the Pantry. Personal Protective Equipment is stored in the garage.


Fire extinguishers were last serviced May 1, 2024. Facility has a sprinkler system and combination smoke/carbon monoxide detectors located throughout the facility that are serviced through an outside vendor. Most recent inspection was conducted on 04/15/2024. Most recent fire/disaster drill was conducted 01/12/2024. Client cash resources were reviewed. LPAs advised Licensee on keeping a P&I sheet with the money at all times.

Five staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Stanley Alli (6040634735) expires 6/16/2024.

Continued on LIC809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOLA MANOR
FACILITY NUMBER: 496804104
VISIT DATE: 05/01/2024
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
Continued from LIC809

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 06/01/2024:

LIC 500 Personnel Report

LIC 9020 Resident Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2