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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001012
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:17:50 PM

Document Has Been Signed on 12/29/2022 12:17 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:CIDER HOUSEFACILITY NUMBER:
125001012
ADMINISTRATOR:ROSE, TINAFACILITY TYPE:
735
ADDRESS:207 NEWELL DRIVETELEPHONE:
(707) 725-5704
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 4CENSUS: 3DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Toni Edwards TIME COMPLETED:
12:30 PM
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with House Manager Toni Edwards.

LPA arrived at the facility and had temperature checked and health questions asked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. Facility Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. LPA observed staff were wearing masks during this visit.

During this inspection, LPA followed up on an incident report submitted to CCL on 12/28/2022. The incident was in regards to a clients Christmas money going missing. LPA was informed the money was locked in a drawer on 12/12/2022. On 12/16/2022, staff went to retrieve the money to go shopping and found the key to the drawer missing. On 12/21/2022, the key returned to its normal location, but the money was missing. Law Enforcement was notified and is investigating. Responsible party was notified. Facility has reimbursed C1. Administrator is reviewing video footage to find the person responsible. Facility has changed procedures in regards to client money to ensure only the Administrator has access.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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