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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 086804160
Report Date: 07/01/2024
Date Signed: 07/01/2024 02:28:19 PM

Document Has Been Signed on 07/01/2024 02:28 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:GLEN HAVEN DAY PROGRAMFACILITY NUMBER:
086804160
ADMINISTRATOR/
DIRECTOR:
HALL, JACOBFACILITY TYPE:
775
ADDRESS:680 E. WASHINGTON BLVDTELEPHONE:
(707) 954-3113
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY: 30CENSUS: 10DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Jacob HallTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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At approximately 1:20PM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced at this Licensed Day Program to conduct an Annual Required Inspection. LPA met with Licensee Jacob Hall and toured the facility. This Day Program operates Monday -Friday. There were 10 Clients and 5 Staff present at the time of this inspection. The facility consists of an office, two large activity rooms, a quiet room, and a bathroom. LPA observed the facility was a comfortable temperature and found all exits and walkways to be unobstructed. The facility grounds were also kept clean and without hazards. Clients bring lunches. Snacks are available for clients.
Toxins are centrally stored in a locked closet. Water temperature measured within regulation between 105 and 120 degrees at faucets accessible to clients. Client money is not handled by facility. Day Program staff do not currently dispense medication, but if Clients are taking medication, facility will keep client's medications centrally stored and locked in a cabinet. Clients do crafts, games, puzzles and other activities in the community while at program. At approximately 1:45PM, LPA reviewed 5 of 10 client files and found files to be thorough and contain current client care assessments and individualized Service Plans. Staff records were also found to be current, including staff first aid and CPR training verification. Disaster drills are conducted twice annually. Carbon monoxide detector was present.

No deficiencies were found in the areas inspected, No citations issued during today’s visit.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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