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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804155
Report Date: 11/21/2023
Date Signed: 11/21/2023 01:28:00 PM

Document Has Been Signed on 11/21/2023 01:28 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:HE&RT LLCFACILITY NUMBER:
496804155
ADMINISTRATOR:NG, ERICAFACILITY TYPE:
734
ADDRESS:5679 QUEEN ANNE DR.TELEPHONE:
(707) 479-0276
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 3DATE:
11/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Erica Ng, AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analysts (LPAs) Christi Coppo and Victoria Bertozzi arrived unannounced to conduct a pre-licensing inspection and was greeted by Celio Buta, Psychiatric Technician. Facility Administrator, Erica Ng arrived later at approximately 9:00am. Facility currently has three residents in care.

At approximately 9:15am LPAs and Erica Ng, Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs 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 and labeled. Kitchen cabinet containing cleaning supplies was locked.

Facility is a one story residence with four bedrooms, two and a half bathrooms, an office and common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Shower room #2 is being cited on current facility, Romana Home 496803748, for not having proper drainage. Facility to provide plan addressing how they will ensure proper draining of water and to mitigate tripping and falling hazards as well as water damage to floor. Once plan of correction is received, LPA to return and continue pre-licensing inspection. Water temperature read at 105.3 and 103.2 degrees F which is not within regulation of 105 & 120 degrees F. LPAs advised Administrator to adjust water heater so that water dispenses at temperature within regulation of 105 & 120 degrees F, Technical Advisory given.

Facility has sufficient items used for cooking and eating. Facility has a locked closet in the office area used for centrally stored medications. Cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in a cabinet in the laundry room. Perishable and non-perishable foods are stored per regulation. Facility has areas inside and outside for visiting and activities.


Report continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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 2
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: HE&RT LLC
FACILITY NUMBER: 496804155
VISIT DATE: 11/21/2023
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Continued from 809...

Facility received an approved fire clearance dated March 23, 2023 that allows for up to four bedridden residents. Currently facility has one resident (R1) that utilizes the living room as mostly a private area. Upon LPA arrival, LPA observed that facility had placed a partition blocking entrance to living room. Per interview with Administrator, facility moved R1's television into living room as R1 prefers to spend most time in the living room. Per Administrator, R1 does sleep in their room, not in the living room. LPAs did observe resident bedroom to have bed and CPAP machine, indicating R1 does indeed sleep in their bedroom. LPA advised per Title 22 regulation 85087(a)(3) no common rooms may be used as a resident bedroom. There is a 2nd common area, the family room, that is utilized for activities and leisure by residents.

Fire extinguishers were last inspected July 27, 2023. Facility has a backup generator for use during a power outage. Medication is centrally stored in a locked cabinet in the office. Erica Ng Administrator Certificate 6038466735 expires 04/10/2024.

LPAs and Administrator observed white gate in backyard is missing top screw that requires repair. Per Administrator, facility is aware of missing screw and is going to have fence repaired immediately. LPAs observed hose located in center part of patio leading to side yard to be a tripping hazard. LPAs advised Administrator to remove all tripping hazards from outside recreation area. LPAs advised Administrator to be sure to have walkways clear of falling acorns as they present a tripping hazard as well.

LPA will return at a later date to complete pre-licensing.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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