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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001012
Report Date: 11/08/2022
Date Signed: 11/08/2022 11:56:09 AM

Document Has Been Signed on 11/08/2022 11:56 AM - 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:CIDER HOUSEFACILITY NUMBER:
125001012
ADMINISTRATOR:ROSE, TINAFACILITY TYPE:
735
ADDRESS:207 NEWELL DRIVETELEPHONE:
(707) 725-5704
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 4CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Taleisha RoseTIME COMPLETED:
12:15 PM
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At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted to CCL on 11/04/2022. LPA met with Taleisha Rose. The incident was in regards to a choking incident that occurred at the Day Program 11/03/2022. Based on a record review, C1 did not have any advisories listed in their physician report or care plan. There was no history of swallowing issues and C1 was not on a special diet. LPA received copies of documents.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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