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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570301295
Report Date: 10/10/2023
Date Signed: 10/10/2023 06:14:28 PM

Document Has Been Signed on 10/10/2023 06:14 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:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Samantha Young, AdministratorTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection and met with Administrator Samantha Young. There are currently 11 residents at the facility; most of whom attend either a job or day program.

Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. The facility was decorated for Halloween and some of the decorations were made by the residents. 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 in the office 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 and grab bars for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). All staff have CPR/First Aid Training. Infection Control Plan received. There were 5 Fire Extinguishers that were recently serviced (03/28/2023), two (2) carbon monoxide detectors (operational) and a hard-wired Fire Alarm System. The facility was inspected by the Fire Department on 03/27/2023 and there were no Fire Code violations. The facility has a Disaster Drill once a month. There are ample supplies in case of emergency.

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

Exit interview conducted with staff and copy of this report left to file.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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