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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804127
Report Date: 02/06/2024
Date Signed: 02/06/2024 12:27:09 PM

Document Has Been Signed on 02/06/2024 12:27 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:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Theresa Harrison, AdministratorTIME COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Theresa Harrison. Facility contact information was reviewed.

At approximately 9:15am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 106.1 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 2/24/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 1/29/2024. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted a review of 3 resident and 2 staff records. All required documentation present.

At approximately 11:15am LPA and Admin reviewed cash and cash records.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the kitchen. No deficiencies.


Report continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DOUGLAS HOME
FACILITY NUMBER: 496804127
VISIT DATE: 02/06/2024
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Continued from 809C...

Theresa Harrison Administrator Certificate 6024312735 expired 1/27/2025. All fees are current as of this time.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond
Deed or Mortgage

No deficiencies cited during this inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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