496804156-8-26-2024-21-AS-ALOA-D8HQDZ-20240826120534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804156
Report Date: 08/26/2024
Date Signed: 08/26/2024 12:05:55 PM

Document Has Been Signed on 08/26/2024 12:05 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:	PENNGROVE GARDENS		FACILITY NUMBER:	496804156
ADMINISTRATOR/ DIRECTOR:	CARDENAS, CRISANTE		FACILITY TYPE:	740
ADDRESS:	1895 ALAN DRIVE		TELEPHONE:	(707) 327-6968
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY: 8		CENSUS:	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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08/26/2024, Licensing Program Analyst (LPA) Loera and (LPM) Bertozzi conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently eight(8) residents in care. Facility approved/cleared for 8 non-ambulatory, and three(3) bedridden, and hospice waiver approved for three(3).

At approximately 9:20am, LPA and LPM toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured within the range of 105 to 120 degrees F. Fire extinguishers were last inspected July, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located in the garage and laundry room and under the kitchen sink and found to be secured. LPA and LPM conducted spot medication count and found all prescription medication to be centrally stored and inaccessible to residents in care.

At approximately 10:15 am, LPA and LPM conducted a review of five(5) resident records. Reviewed files had the required documentation.

continued on LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PENNGROVE GARDENS	FACILITY NUMBER: 496804156
	VISIT DATE: 08/26/2024

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At approximately 11:00 am/pm, LPA and LPM conducted review of five(5) staff records/training. Upon a review of staff records, LPA and LPM found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

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
LIC309- Administrative Organization
Liability Insurance
(emergency/disaster plan and infection control plain - if any changes have been made)

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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