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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804127
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:41:30 PM

Document Has Been Signed on 03/10/2023 03:41 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:DOUGLAS HOMEFACILITY NUMBER:
496804127
ADMINISTRATOR:HARRISON, THERESAFACILITY TYPE:
735
ADDRESS:350 BOAS DRTELEPHONE:
(707) 539-5351
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 3DATE:
03/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Applicant, Theresa HarrisonTIME COMPLETED:
03:51 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant, Theresa Harrison. Facility has applied for a Change of Ownership.

Upon arrival, LPA was greeted by facility staff. Facility is a one story residence with three client bedrooms (one shared, two private), a staff bedroom, one client bathroom and common areas. All client rooms are furnished per regulation. Bathroom showers have non-skid mat and grab bars. Water temperature read at 105 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility stores centrally stored medication in a locked cabinet in kitchen. Cleaning supplies and toxins are locked in a cabinet under the sink and in the garage. Perishable and non-perishable foods observed per regulation. Facility has areas inside and outside for visiting and activities. Facility maintains an emergency supply of food and water.

Facility received an approved fire clearance dated January 25, 2023 that allows for four ambulatory and two non-ambulatory clients. Carbon Monoxide detector was tested and operational.

LPA gave Administrator information on how to sign up for the Guardian. LPA confirmed that Applicant is signed up to receive the Provider Information Notices (PINs) that the department sends out.

Component III is waived due to Applicant being an existing Licensee.

LPA will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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