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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804141
Report Date: 08/04/2023
Date Signed: 08/04/2023 11:14:11 AM

Document Has Been Signed on 08/04/2023 11:14 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: 3DATE:
08/04/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Anton Kuehnhackl (Licensee)TIME COMPLETED:
11:29 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a post-licensing inspection. LPA met with Licensee, Anton Kuehnhackl. All clients were attending to Day Program. Required postings observed. Upon arrival LPA was screened and signed in per facility protocol.

At 9:00am LPA/Licensee toured building and grounds which were found to be clean and in good repair. Exits and walkways were free from obstructions. Facility had sufficient perishable and non-perishable food. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. There is outdoor space for activities. LPA obtained a copy of activity calendar and weekly dated menu was also observed. All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by regulations. Carbon monoxide detectors were present throughout the facility. Fire extinguishers inspected were charged and current as of 07/23. Facility has smoke detectors and sprinklers. Fire panel was last inspected 07/23. Last disaster drill was conducted on 06/19/23. Hot water temperature measured at 110.7 and 114.8 degrees in resident's bathrooms which is within regulation. Bathrooms had necessary grab bars and non-slip mats. Medications were centrally stored and secured. Toxins were locked and secured. Facility had extra fresh linens and hygiene supplies available for residents.

During today's post-licensing inspection, LPA reviewed three residents and two staff files. Residents have current medical assessments and individualized care plans. Staff records indicated that CPR/1st aid and staff have received required annual training hours. Admission agreements were updated indicating the change of ownership. Administrator certificate for Rudolf Anton Kuehnhackl 6047570735 expires 3/12/24.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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: 08/04/2023
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Continued from LIC809...

LPA is following up on an incident report submitted to CCL. Per incident report, on 7/1/23 while spending some vacation time client (C1) slapped staff (S1) and another client (C2) while they were in the pool, it appeared that C1 felt that S1 and C2 were sitting too close to their personal space. S1 immediately checked on both clients, no injuries were noted, then C1 apologized for their behavior and responsible parties were notified including C1's Physician. During today's visit, LPA was provided with C1's care plan and medical records indicating that C1 was evaluated on 7/11/23 and has a follow up appointment with a specialist for further evaluation on 8/7/23. Also, no changes were made to their medication and no further incidents have happened since the one reported.

No citations issued during today's visit. Exit interview was conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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