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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126804201
Report Date: 08/06/2024
Date Signed: 08/06/2024 12:37:45 PM

Document Has Been Signed on 08/06/2024 12:37 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:HYPERION CRTFFACILITY NUMBER:
126804201
ADMINISTRATOR/
DIRECTOR:		GILBERT, DAVIDFACILITY TYPE:
772
ADDRESS:528 N STTELEPHONE:
(530) 300-4238
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 10CENSUS: 0DATE:
08/06/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:David GilbertTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant and toured the facility. The Facility is a 5-bedroom, 3-bathroom, single story house. Fire extinguishers were mounted and charged. The fire system was being tested during this visit. Carbon monoxide detector was present. There was a locked area for medications, files and several for toxins and cleaning supplies. Beds were made with appropriate linens. 4 of 5 Client rooms contained the required furniture. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents.
Approval of this application is pending completion of the following:
  • Completion of Kitchen
  • Completion of Medication room
  • Completion of Bathroom #2
  • Completion of Bedroom #2
  • Window blinds in bedrooms
  • Paper towel dispensers in bathrooms
  • Removal of construction debris
  • Evidence of required food items

Applicant will submit photos of completed items to LPA upon completion.
Upon receipt of all items, this application will be forward for final review and approval by Licensing Program Manager.

Component III orientation was completed during this visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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