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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001012
Report Date: 02/12/2025
Date Signed: 02/12/2025 09:29:37 AM

Document Has Been Signed on 02/12/2025 09:29 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/
DIRECTOR:
ROSE, TINAFACILITY TYPE:
735
ADDRESS:207 NEWELL DRIVETELEPHONE:
(707) 725-5704
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 4CENSUS: 4DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Kaye HahnerTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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At approximately 8:05AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Caregiver Kaye Hahner and explained the purpose of the visit. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and yard. In the areas toured no immediate health, safety, or personal rights violations were observed. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supplies of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit was present. Fire extinguishers were fully charged. Smoke detectors are operational. Two rooms did not have smoke detectors due to battery replacement. Staff could not find the Carbon Monoxide Detector but is sure there is one present. Licensee will notify LPA when the smoke detectors are replaced and the carbon monoxide detector is located. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months.

At approximately 8:20AM, LPA reviewed Staff and resident files. All resident files contained the required documentation. Staff files reviewed contained evidence of completed annual training. First Aid certification was current.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:


Current Rental/Lease Agreement
LIC500- Personnel Report
Evidence of Current Surety Bond

No citations were issued during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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