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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803772
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:26:42 AM

Document Has Been Signed on 10/22/2024 11:26 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/
DIRECTOR:
KIM JOHNSONFACILITY TYPE:
735
ADDRESS:500 SILER LANE UNIT BTELEPHONE:
(707) 798-6319
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 25CENSUS: 24DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Kim JohnsonTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required inspection. LPA met with Administrator Kim Johnson. At approximately 8:30AM, LPA toured the building and grounds. LPA observed an office in the process of construction. LPA was informed the work is being completed by a Licensed contractor and will be complete by the end of the week. The new room will be used as an office/ medication room. Kim will submit an updated facility sketch. 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 above regulation between 105 and 120 degrees F at faucets accessible to clients. The water heater was turned down at the time of this inspection. 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 10:00AM, LPA reviewed 8 Client records and 3 staff records, which were all found to be well organized, thorough and contained the required documentation. First aid certification was current in staff files reviewed. Administrator's Certificate expired on 04/08/2024 and was submitted for renewal on time.

No citations issued during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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