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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804127
Report Date: 03/12/2025
Date Signed: 03/12/2025 12:44:09 PM

Document Has Been Signed on 03/12/2025 12:44 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/
DIRECTOR:		HARRISON, THERESAFACILITY TYPE:
735
ADDRESS:350 BOAS DRTELEPHONE:
(707) 539-5351
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Theresa Harrison, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:58 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Theresa Harrison, Administrator.

At approximately 10:00am LPA and Admin toured the building and grounds. The facility was found to be 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. Linoleum in kitchen could present as a tripping hazard. Admin agrees to have linoleum replaced by 4/12/25 and will send pictures to CCL of completed floor replacement in kitchen by no later than 4/12/25.

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 102 degrees F which is not within the allowable range of 105 to 120 degrees F. LPA let water run for about 3 minutes. Admin will work with facility maintenance man to get water temperature up to at least 105 degrees F without having to wait more than 3 minutes for water to reach temperature within regulation.

Fire extinguishers were last inspected 2/17/25. Smoke/Carbon Monoxide detectors located throughout the facility are operational. Facility’s last quarterly disaster drill was conducted 12/14/25. LPA advised Admin to be sure to complete drills within the quarter. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted a review of four [4] resident records. All required documentation present.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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: DOUGLAS HOME
FACILITY NUMBER: 496804127
VISIT DATE: 03/12/2025
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Continued from 809...

At approximately 11:30am LPA conducted review of 1 staff record. No deficiencies cited.

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

At approximately 12:30pm LPA and Admin reviewed cash resources. Receipts present. No deficiencies cited.

Theresa Harrison, Administrator Certificate 7034451735 expires 01/27/2027.



No deficiencies cited.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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