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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804141
Report Date: 04/25/2023
Date Signed: 04/25/2023 10:34:10 AM

Document Has Been Signed on 04/25/2023 10:34 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MILLS MANORFACILITY NUMBER:
496804141
ADMINISTRATOR:KUEHNHACKL, ANTONFACILITY TYPE:
735
ADDRESS:9790 OCONNELL RDTELEPHONE:
(707) 824-8403
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 4DATE:
04/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Anton Kuehnhackl (Applicant)TIME COMPLETED:
10:49 AM
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Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a Pre-Licensing Inspection and component III. LPA met with Applicant, Anton Kuehnhackl. This pre-licensing is for a change of ownership. There are four clients in care.

LPA/Applicant initiated a tour of the facility and made the following observations: Facility is a two story residence, but upstairs is for staff bedrooms only. Downstairs is the area that includes three shared ambulatory resident bedrooms (room#1, 2 and 3), two bathrooms, one dining room, one kitchen with pantry area, laundry room, another staff bedroom and living room. Facility received an approved fire clearance dated February 19, 2023 that allows for 6 ambulatory residents. LPA discussed with Applicant the importance of having approval for non-ambulatory residents and Applicant wants to proceed to update their fire clearance and obtain approval for non-ambulatory bedrooms for clients. LPA will request the application unit in Sacramento follow-up on this and obtain an updated fire clearance with specific clearance approval.
Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms measured at 113 and 115.5 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Bathroom showers have non-skid shower floors/mats and grab bars. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MILLS MANOR
FACILITY NUMBER: 496804141
VISIT DATE: 04/25/2023
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Continued from LIC809...

Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Medications were centrally stored and locked. Client's cash resources and medications were reviewed. Fire extinguisher were last inspected January 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Last disaster drill was conducted on 12/5/22. Facility does have a current menu and activity calendar. Emergency supplies were observed including flashlights and water. First aid kit was fully stocked.

Three staff files and four resident files were reviewed. Staff have required First Aid Certificates. Clients records have updated care plans on file. Administrator Certificate for Administrator Rudolf Anton Kuehnhackl 6047570735 expires 3/12/24. Applicant and LPA discussed their Emergency Disaster Plan and Infection Control Plan. LPA observed required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. LPA and Applicant discussed that all resident admission agreements would need to be updated upon Licensure. LPA confirmed that Applicant signed up for the Guardian and Provider Information Notices (PINs) that the Department sends out. Component III was conducted with Applicant. LPA will submit copy of the facility report to the Centralized Application Unit (CAB). Per Applicant, the old facility has a hospice waiver approved for one resident and they will apply to keep hospice waiver. LPA will conduct a subsequent pre-licensing inspection after updated fire clearance is received.

No deficiencies cited at today’s inspection. Exit interview was conducted with Applicant and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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