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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102765
Report Date: 03/10/2022
Date Signed: 03/10/2022 01:47:08 PM

Document Has Been Signed on 03/10/2022 01:47 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:CEDARS OF MARIN ROSS CAMPUS, THEFACILITY NUMBER:
210102765
ADMINISTRATOR:ANDERSON, STACYFACILITY TYPE:
735
ADDRESS:115 UPPER ROADTELEPHONE:
4154545310
CITY:ROSSSTATE: CAZIP CODE:
94957
CAPACITY: 55CENSUS: 48DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Stacy Anderson-Administrator & Rodric Robinson-Dir. of Residential ServicesTIME COMPLETED:
01:47 PM
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Licensing Program Analyst (LPA) Hansen arrived to conduct an unannounced annual 1-Yr Infection Control inspection of the Cedars of Marin Ross Campus. LPA toured the interior and exterior of the facility with Associate Director of Residential Services Stacy Anderson and Rob Robinson Director Residential Services.

At approximately 11:50 AM LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The facility consists of three buildings divided into four halls. McIvor Hall and Collins Hall are in one building. McIvor and Collins Halls each house 6 clients. Peterson Hall has a total of 21 clients and administrative and medical offices. Pope hall has 15 clients. During today's inspection 9 staff are on shift and 5 clients present with the rest of the clients being at day programs.

The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. There is a sufficient supply of hygiene products and linens on hand for client use. Water temperature measured 105.2 to 119.1 degrees F throughout the buildings which is within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged and dated 1/25/2022. All buildings have functioning smoke detectors, carbon monoxide detectors, pull station fire alarms with audio/visual alarms and sprinklers. The fire alarms are tested by a contractor, Fire King Fire Protection, Inc, last inspection 10/26/2021. Fire drills are done monthly and are documented, last 3/9/2022. Each hall has a locked toxin/chemical storage closet, LPA observed toxins inaccessible to clients. LPA made observation in 10 client private rooms. Each hall has a locked medicine storage room where medications are centrally stored.

Continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CEDARS OF MARIN ROSS CAMPUS, THE
FACILITY NUMBER: 210102765
VISIT DATE: 03/10/2022
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Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 3/04/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Each of the 3 halls have check in and temperature log in stations. Posters have been placed at facility. Facility has PPE supply stored in locked kitchen cabinet, in the gym, and a storage sheds next to Pope Hall. Staff had all PPE training required as well have been N95 Fit Tested. All staff and clients have been fully vaccinated and received their COVID booster shots and all staff work exclusively at this facility.



LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1st Aid certification for staff.

LPA was presented with Administrator Certificate for Stacy Anderson #6030360735 with expiration date of 2/26/2022 and with proof of State Certification receiving request for new certificate on 1/20/2022.


There were no deficiencies cited at this time.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2022:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan
LIC400-Affidavit Regarding Client Cash Resources
LIC 9020 – register of Facility Client’s
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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