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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803772
Report Date: 10/09/2023
Date Signed: 10/10/2023 08:12:44 AM

Document Has Been Signed on 10/10/2023 08:12 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:WINDSONGFACILITY NUMBER:
126803772
ADMINISTRATOR:KIM JOHNSONFACILITY TYPE:
735
ADDRESS:500 SILER LANE UNIT BTELEPHONE:
(707) 798-6319
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 25CENSUS: 21DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kim JohnsonTIME COMPLETED:
03:30 PM
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***This is an amended report to correct the time of visit and record reviews.***
At approximately 1:15PM, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced Annual Required inspection to this facility and met with Administrator Kim Johnson. At approximately 1:30PM, LPA toured the building and grounds. LPA observed a light switch in one bathroom with a broken cover plate. Repair was underway. The facility recently repaired a section of the roof that was leaking. The ceiling was damaged due to the leak. LPA was informed the section will be repaired when it dries. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were tested and found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detector was present. Disaster Drills are conducted quarterly.

At approximately 2:30PM, LPA reviewed 5 Client records and 3 staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed. Administrator's Certificate was current with an expiration date of 04/08/2024.

No citations issued during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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