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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570301295
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:13:25 PM

Document Has Been Signed on 11/10/2022 12:13 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:SUMMER HOUSE INC.FACILITY NUMBER:
570301295
ADMINISTRATOR:YOUNG, SAMANTHAFACILITY TYPE:
735
ADDRESS:206 5TH STTELEPHONE:
(530) 662-8493
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 12CENSUS: 11DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Samantha Young, AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection and met with Administrator Samantha Young. The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry; temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. The facility was decorated with Fall decor, giving it a nice homey feel. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). Administrator and all staff had a mask on during the LPA's inspection. Staff working in kitchen were wearing masks and gloves. All staff have CPR/First Aid Training. Mitigation plan was approved by the Department and Infection Control Plan also received. There were 3 Fire Extinguishers that were recently serviced (04/01/2022), there were two (2) carbon monoxide detectors (operational) and a hard-wired Fire Alarm System,
There were eleven (11) residents in care at the facility during this inspection. 9 residents were at "Program" during the time of inspection.

No deficiencies during today's inspection.
No citations issued.

Exit interview conducted with the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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