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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803630
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:18:41 PM

Document Has Been Signed on 01/23/2025 04:18 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:PETERSON LANE HOMEFACILITY NUMBER:
496803630
ADMINISTRATOR/
DIRECTOR:		NARCISO, JENNICA AFACILITY TYPE:
734
ADDRESS:1618 PETERSON LANETELEPHONE:
(707) 978-2573
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 5CENSUS: 5DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jhara Joniga-LVNTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a Required-1 Year inspection, on 1/23/25 at approximately 1;00pm and met with LVN Jhana Joniga. LPA observed three (3) other staff on duty, Michael Monteclaro, Angelina Pandolino, and Bernard Heath. Fely Juanson, Assistant Administrator was notified of LPA's arrival and came to the facility to meet with the LPA.

There are five (5) residents in care; Four were at day program during the inspection.

Facility is fire cleared for five (5) non-ambulatory and/or bedridden. Fire extinguishers were serviced and tagged as required. Smoke alarms are hard wired, facility is fire sprinkled, and has two carbon monoxide detectors. Emergency disaster drills are held on a monthly basis,per record review; The last emergency disaster drills were held on 1/6/25, 12/4/24, and 11/4/24.

The facility was observed to be at a comfortable temperature. The facility was clean and orderly Facility has auditory alarms on all exit doors. The facility has a generator as there 2nd required power source. The generator runs a check every week to ensure it is working properly. All bathrooms have grab bars, and roll in showers. The facility had a sufficient supply of perishable and non-perishable food.

Facility had a sufficient supply of hygiene products, cleaners/disinfectants, incontinent supplies, personal protective equipment (PPE), and paper products. Facility had sufficient furnishings for resident use. All common areas, hallways, bathrooms, and resident rooms have sufficient lighting. Hot water was checked at 115.4 degrees Fahrenheit, which is within regulation. Medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care.

LPA reviewed five (5) resident files, including medications, and medication records/logs.

LPA reviewed four (4) staff files, including training. All staff had required criminal record clearance. All staff had first aid and cpr certification.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: PETERSON LANE HOME
FACILITY NUMBER: 496803630
VISIT DATE: 01/23/2025
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Continued from LIC809...

LPA requested the following updated documents by 2/23/25.
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Surety bond- if handling cash
Emergency Disaster Plan- if any changes, submit a copy- if no changes, sign & date last page, and submit
Register of residents
Copy of Administrator certificate

LPA observed a large barbecue grill outside on the cement patio in-between two resident room fire exit doors, which partially blocked the two fire exit paths from these rooms. LPA observed a wheelchair and tray table blocking the fire door exit in a resident's room. This has been discussed in past inspections with facility staff, including the facility Administrator. The resident rooms fire exit doors being blocked and/or partially blocked pathway is not in line with fire clearance approval, This deficiency will be cited, 80020(a) Fire Clearance-All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22,
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Administrator Assistant, Fely Juanson.
Appeal rights provided to the Administrator Assistant.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 04:18 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/23/2025 at 03:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PETERSON LANE HOME
FACILITY NUMBER: 496803630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020(a) Fire Clearance-All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed a large barbecue grill outside on the cement patio in-between two resident room fire exit doors, which partially blocked the two fire exit paths from these rooms. LPA observed a wheelchair and tray table blocking the fire door exit in a resident's room. This has been discussed in past inspections with facility staff, including the facility Administrator. The resident rooms fire exit doors being blocked and/or partially blocked pathway is not in line with fire clearance approval, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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CLEARED BY STAFF 1/23/25, DURING THE INSPECTION-STAFF MOVED THE WHEELCHAIR AND TRAY TABLE FROM IN FRONT OF THE RESIDENT'S FIRE EXIT DOOR; STAFF MOVED THE LARGE BARBECUE GRILL ON THE CEMENT PATIO FROM IN-BETWEEN THE TWO RESIDENT ROOM FIRE EXIT DOORS.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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