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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804105
Report Date: 07/24/2024
Date Signed: 07/24/2024 02:52:12 PM

Document Has Been Signed on 07/24/2024 02:52 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ELSA HOMEFACILITY NUMBER:
496804105
ADMINISTRATOR/
DIRECTOR:
ALLI, STANLEYFACILITY TYPE:
735
ADDRESS:6028 ELSA AVENUETELEPHONE:
(707) 540-0907
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 4CENSUS: 3DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Stanley Alli & Funmilola(Lola) AlliTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection of facility on 7/24/2024 at approximately 11:00 AM, and was met by Vanesa, caregiver. The Licensee’s/Administrator Stanley & Funmiola (Lola) Alli were contacted by staff to notify of LPA's arrival. The Licensee/Administrator arrived shortly after. Currently there are three clients in care. There were no clients at facility during time of inspection, they had already been picked up by the day program.

At approximately 11:30 AM, LPA and Licensee’s/Administrator toured the buildings and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be clear and unobstructed. There was an appropriate supply of perishable & nonperishable foods for clients in care per regulations. Hot water measured 116.7 degrees F & 118.4 degrees F, which is within regulations of between 105 degrees F and 120 degrees F in two bathroom faucets accessible to clients. Bathrooms also contained grab bars and non-slip flooring/mats for safety as needed. LPA observed a sufficient supply of cleaners, hygiene products, and paper products. Medications are centrally stored in med cart, inaccessible to clients in care. Cleaners/toxins were locked, making them inaccessible to clients in care. LPA observed a sufficient supply of linens for client use. The facility has sufficient furnishings for clients use. The facility was clean and orderly, including the backyard area. Smoke alarms were working properly when checked, some of which are also carbon monoxide detectors. Fire extinguishers were serviced last on 7/11/2024. Disaster drills are conducted quarterly with the last drill conducted 6/30/2024.

At approximately 12:15 PM, LPA reviewed 3 of 3 Client records and 5 of 5 Staff records, which were all found to be well organized, thorough and contained the required documentation. First Aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. Administrator’s Certificate for Stanley Alli expired 6/16/2024 and is pending for renewal and Funmilola (Lola) Alli Administrator’s certificate is current with expiration of 10/21/2024.
Continued LIC809C.....
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELSA HOME
FACILITY NUMBER: 496804105
VISIT DATE: 07/24/2024
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LPA is requesting the following documents be updated and submitted to CCL by 8/14/24:
LIC 500-Personnel Report
LIC 308-Designation of Responsibility (if changes)
LIC 9020-Register of Facility Client’s
LIC 400 - Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Emergency Disaster Plan (if changes)
Administrator Certificate

There are no deficiencies cited today.
Exit interview conducted with Administrator’s.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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