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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890095
Report Date: 12/27/2022
Date Signed: 12/27/2022 02:19:15 PM


Document Has Been Signed on 12/27/2022 02:19 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:ALLURE SENIOR CARE INCFACILITY NUMBER:
496890095
ADMINISTRATOR:MERA SHAUGHNESSYFACILITY TYPE:
740
ADDRESS:2008 DENNIS LANETELEPHONE:
(707) 696-6053
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 0DATE:
12/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mera Shaughnessey-LicenseeTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection and met with Licensee/Administrator Mera Shaughnessey; Mera's administrator certificate #6010796740 is current and expires 12/15/2023. This application is a change of location of Allure Senior Care, to address 2008 Dennis Lane, Santa Rosa. Licensee has submitted documents as requested for the change of location application. Facility will have a new license number, #496890095.

Facility has a fire clearance approval by the Santa Rosa Fire Department for a total of six non-ambulatory and/or bedridden-effective 12/5/2022. Facility has an approved dementia plan, and a hospice approval for three(3) residents.

Facility will operate with an awake night staff and Licensee will ensure sufficient 24/7 staffing at all times.

Hot water was checked at 112.8F which is within regulation. All exits were unobstructed in the home. Lights/power were on and operational. Cable television and phone service are to be transferred this Thursday, 12/9/22, a scheduled appointment, per Licensee. Currently, the facility has a cell phone for use as needed and internet connection for Hulu, Netflix, and Youtube, etc.

There are nine(9) smoke alarms that are also carbon monoxide detectors, all were working appropriately during the inspection. Fire extinguishers, two (2) are fully charged as required, and tagged, 12/5/22.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALLURE SENIOR CARE INC
FACILITY NUMBER: 496890095
VISIT DATE: 12/27/2022
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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. LPA observed a closet for storing medications, this closet has a key lock securing the medications. All bathrooms had grab bars for resident use. Postings noted to be current and in compliance with regulations. Facility does have an infection control plan as required, and an emergency disaster plan; Facility does have a generator that can be used as needed for charging things like cell phones, batteries, lights/lanterns. Toxins/cleaners will be locked and secured and inaccessible to residents in care. Facility has a supply of Personal Protective Equipment (PPE) for use as needed. Station set up at front door area with sanitizer gel, and where a staff person on duty will ensure screening as needed. All postings required were posted, and visible upon arriving to the front entrance door outside of the facility and inside the facility.

LPA requested the following updated forms to be submitted to Community Care Licensing by 12/30/2022:
LIC 308 Designation of Facility Responsibility (1 person per form)
LIC 500 Personnel Report
LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
LIC 402 Surety Bond(if handling cash)
LIC 610E Emergency Disaster Plan/Evacuation Plan
LIC 9020 Register of Facility Residents
Copy of current Administrator's Certificate
Copy of Infection Control Pllan

LPA conducted a component III orientation with Applicant Mera Shaughnessey.

Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this inspection. The application is approved for licensure, effective 12/27/2022.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC809 (FAS) - (06/04)
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