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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804104
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:32:34 PM

Document Has Been Signed on 03/20/2025 04:32 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:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Licensee, Lola Alli
Administrator, Stanley Alli
TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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03/20/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 4 clients in care.

At approximately 1:45 pm, LPA, Licensee and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. Emergency food and water is stored in the Pantry and in the garage.

All rooms were furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 115.5 and 110.1 degrees F within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05/2024. Facility has a sprinkler system and combination smoke/carbon monoxide detectors located throughout the facility that are serviced through an outside vendor. Toxins, sharps and other items that could pose threat if available to clients were located in the garage and in the kitchen and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 4 client records. All records had the required documentation. LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

Most recent fire/disaster drill was conducted 03/15/2025. Client cash resources were reviewed.


continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LOLA MANOR
FACILITY NUMBER: 496804104
VISIT DATE: 03/20/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/21/2025:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC9020- Register of Facility Clients

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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