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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804136
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:04:19 PM

Document Has Been Signed on 03/21/2023 04:04 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:HUNTER HOMEFACILITY NUMBER:
496804136
ADMINISTRATOR:ALLI, FUNMILOLA I.FACILITY TYPE:
734
ADDRESS:604 HUNTER LANETELEPHONE:
(909) 908-2766
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 0DATE:
03/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Applicants, Stanley and Lola AlliTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicants, Stanley and Lola Alli.

LPA initiated a tour of the facility at approximately 3:00pm and made the following observations: Facility is a one story residence with four single client bedrooms, two bathrooms and common areas. Passageways were free from obstruction. All client rooms are furnished per regulation. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathroom read at 112 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Refrigerator temperature read within regulation. Emergency food and water supplies are stored in the kitchen pantry. LPA discussed rotating food so that food doesn't expire. Facility backyard has an area for visiting and activities.

Facility received an approved fire clearance dated February 14, 2023 that allows for four bedridden clients. Fire Extinguishers were last serviced February 2023. Facility has combination smoke and carbon monoxide detectors. Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient. Facility generator is not yet installed but facility has a plan to rent a generator if needed.

LPA observed required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster and Resident's Rights.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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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: HUNTER HOME
FACILITY NUMBER: 496804136
VISIT DATE: 03/21/2023
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Continued from LIC809

Medications and files will be secured in locked cabinets. LPA confirmed that Applicant is signed up for the Guardian and Provider Information Notices (PINs).

Component III is waived due to Applicant being a current Licensee.

LPA will notify Application Unit so application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC809 (FAS) - (06/04)
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