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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804195
Report Date: 11/28/2023
Date Signed: 11/28/2023 11:43:15 AM


Document Has Been Signed on 11/28/2023 11:43 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:TREE HAVEN ESTATE 1 LLCFACILITY NUMBER:
496804195
ADMINISTRATOR:MARIMBI, MARTHAFACILITY TYPE:
740
ADDRESS:359 TREE HAVEN LANETELEPHONE:
(707) 304-9106
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:8CENSUS: 0DATE:
11/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Martha Marimbi, AdministratorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a pre-licensing inspection and was greeted by Martha Marimbi, Administrator. Facility currently does not have residents in care. Facility has fire clearance for 8 non ambulatory residents. Bedrooms #1 and #2 and the guest house are proposed to have double occupancy. Once obtained, Administrator will submit proof of required Liability insurance.

At approximately 9:00am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed within regulation emergency supply of non-perishable food. Kitchen has locked cabinet that will be used for medication storage and file storage. LPA and Administrator discussed the open area kitchen with range. Administrator will ensure all knobs on range are removed for resident safety when staff is not actively cooking or utilizing range. Two locked drawers are dedicated for sharp knives. Administrator advised they will be changing from latch lock to magnet locks. Sample menu present in dining area as well as activity calendar.

Facility is a one story residence with four bedrooms, three full and five half bathrooms, a guest house which is separate from main building that will be used as a resident room, a dedicated entertainment space, and dining and living room common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Extra linens and bedding observed. Each bedroom has a hanging chandelier that could potentially be a safety hazard. Administrator advised they will be shortening each and every chandelier chain in order to mitigate safety risk.

Smoke and carbon monoxide detectors present and functioning, last serviced September 2023. Five fire extinguishers present and last serviced on March 16, 2023. First aid kit present but missing scissors and thermometer. Per Title 22 regulation 87465(8)(D) scissors are required and per 87465(F) a thermometer is required. Administrator advised they will purchase required scissors and thermometer. Emergency lighting present and functional. LPA observed all required postings and posters present. Administrator advised that they will use personal vehicles for transportation.

Continued on 809C....
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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: TREE HAVEN ESTATE 1 LLC
FACILITY NUMBER: 496804195
VISIT DATE: 11/28/2023
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Continued from 809...

Water temperatures read at: 118 F in kitchen half bath, 117.7 F in main bath, 113 F in guest house, 110 F in bedroom #4, 116 F in bedroom #3, 116.2 F in bedroom #1, and 113 F in bedroom #2, all which are within regulation of 105 & 120 degrees F.

Facility has sufficient items used for cooking and eating. Cleaning supplies and toxins have dedicated locked cabinet in outside laundry room. Laundry space with washer and dryer present in dedicated entertainment area, per Administrator this space will only be used in case of emergency or if outside washer and dryer malfunction. Administrator advised that all potential toxins, soaps and detergents will be stored in outside laundry area. Facility has areas inside and outside for visiting and activities.

All rooms have exit sliding doors with alarms present and functioning. All windows fitted with alarms as well. alarms on and functioning at time of inspection. LPA observed guest house to be separate from main house and per Administrator is intended for resident occupancy, therefore it is required to have a call system. Per Title 22 regulation 87303(i) residents occupying the guest house will need to have the following capacity: (A) operate from each resident's living unit; (B) transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff; (C) Identify the specific resident's living unit.

Facility has outdoor fountain pond with water approximately three feet deep. Pond surrounded by plastic fence measuring approximately 48 inches. Outside emergency exit paths all clear. The two exits on each side of the facility had a padlock on the gate. LPA and Administrator discussed that emergency exit gates shall not be padlocked when residents are in care. Administrator immediately removed padlocks.

Administrator certificate #6051254740 for Martha Marimbi present in facility and shows expiration of 3/21/2025.

The following items to be corrected and or obtained prior to LPA submission of facility's application for approval: fireplace to be adequately screened, call system present for proposed resident(s) occupying guest house, and first aid kit needs to have thermometer and scissors added to kit. Administrator to provide photos of items. Once acceptable photographic proof is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2