496804143-4-20-2023-21-AS-DALO-CR3QGE-20230420120924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804143
Report Date: 04/20/2023
Date Signed: 04/20/2023 12:11:30 PM

Document Has Been Signed on 04/20/2023 12:11 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SENIOR CARE LIVING		FACILITY NUMBER:	496804143
ADMINISTRATOR:	SORENSEN, JANINE		FACILITY TYPE:	740
ADDRESS:	1960 DENNIS LANE		TELEPHONE:	(707) 304-4790
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 0	DATE:	04/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Ami Kumar-Applicant		TIME COMPLETED:	12:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso conducted a pre-licensing inspection and met with Ami Kumar, Applicant, and Janine Sorrenson, who will be the facility's Administrator; Janine's RCFE Administrator certificate number is #6039492740, expires 5/4/2024. Ami Kumar also has a current RCFE Administrator certificate. Facility has a fire clearance approval by the Santa Rosa Fire Department for a total of six(6) non-ambulatory residents, which includes one(1) bedridden approval, effective 3/27/2023. The bedridden fire clearance approval is for resident room #2 only. Facility has an approved dementia plan of operation. The facility has an approved hospice waiver for three(3) residents. The applicant submitted the required infection control plan, and the required emergency and disaster plan for the residential care facility. The Applicant operates two(2) other licensed facilities, and stated that they, Ami Kumar and hired Administrator Janine Sorrenson, understand the requirements of the infection control plan and the emergency disaster plan. Facility will operate with an awake night staff, and Licensee/Administrator will ensure sufficient 24/7 staffing at all times. Hot water was checked at 120.F which is within regulation.. All exits were unobstructed in the home. The homes lights/power was on and operational. Cable was connected, and working properly. The home has internet use available for resident use, telephone service is available, and was working properly during today's visit. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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: SENIOR CARE LIVING	FACILITY NUMBER: 496804143
	VISIT DATE: 04/20/2023

NARRATIVE

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There are seven(7)smoke alarms that are also carbon monoxide detectors, all were working appropriately during the inspection. Fire extinguishers, two (2), were serviced and tagged as required, expires 2/6/2024.

There was sufficient lighting throughout the facility in resident rooms, common areas, bathrooms, and hallways. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. All bathrooms had grab bars for resident use. Required postings were up and visible. There is a large closet that is set up to hold resident medications, it locks and keeps medications inaccessible to residents in care. Toxins/cleaners will locked up in the laundry room, and inaccessible to residents in care.
Facility has a sufficient supply of Personal Protective Equipment (PPE) for use as needed.

LPA conducted a component III orientation with Applicant Ami Kumar and Janine Sorrenson.

Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this inspection. The LPA will send a copy of the report to the Application Unit Analyst; The Application Unit Analyst will notify the applicant of the status of the application.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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