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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804136
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:44:12 AM

Document Has Been Signed on 05/14/2024 11:44 AM - 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/
DIRECTOR:		ALLI, FUNMILOLA I.FACILITY TYPE:
734
ADDRESS:604 HUNTER LANETELEPHONE:
(909) 908-2766
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Administrator Funmilola AlliTIME VISIT/
INSPECTION COMPLETED:
11:58 AM
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Licensing Program Analysts (LPAs) Christi Coppo and Jacqueline Macias arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Funmilola Alli arrived alter at approximately 9:30am. Facility contact information was reviewed.

At approximately 9:30am 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. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, chair, 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 108 degrees F which is within the allowable range of 105 to 120 degrees F.

Two [2} out two [2] fire extinguishers were last inspected 5/14/2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drill was conducted 5/11/2024. Facility has a backup generator for use during a power outage.

At approximately 10:00am LPAs conducted review of five [5] staff records. At approximately 10:45am LPA conducted a review of four [4] resident records. All required documentation present.

At approximately 11:15am LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in locked medication carts. No deficiencies.


Continued from 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 05/14/2024
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Continued from 809...

Funmilola Alli Administrator Certificate 6041281735 expires 10/22/2024. Fees due, gave Admin LIS print out with PIN.

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
Liability Insurance

No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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