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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102765
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:36:49 PM

Document Has Been Signed on 02/14/2024 02:36 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:
(415) 454-5310
CITY:ROSSSTATE: CAZIP CODE:
94957
CAPACITY: 55CENSUS: 46DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Associate Director of Residential Services Stacy Anderson & Staff/ Designee Rosemond Jolissaint TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Hansen arrived to conduct an unannounced annual Inspection of the Cedars of Marin Ross Campus. LPA toured the interior and exterior of the facility with Staff/ Designee Rosemond Jolissaint and was joined by Associate Director of Residential Services Stacy Anderson.

At approximately 9:00 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 13 staff are on shift and 6 clients present with the rest of the clients at day programs.

The amount of fresh and non-perishable foods was within regulation. There is a sufficient supply of hygiene products and linens on hand for client use. Water temperature measured 104.2 degrees F to 120.5 degrees F, falling out of regulation between 105 and 120 degrees F in 3 of 14 faucets accessible to clients in 3 buildings. Maintenance began adjusting water heaters during inspection (see LIC9102 TA). Fire extinguishers last inspections 2/23/2023. 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 2/14/2024. Disaster Drills are conducted monthly and are documented, last 1/12/2024. Each hall has a locked toxin/chemical storage closet, LPA observed toxins inaccessible to clients. LPA observed 10 client private rooms that contained required furnishing per Title 22 Regulations. Each hall has a locked medicine storage room where medications are centrally stored; although LPA observed medication pre-poured for clients in care (see LIC 9102 TA & pics) and were immediately destroyed.

Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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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: 02/14/2024
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LPA reviewed 5 Client records. Based on record review at 11:30 AM with Director 5 out of 5 clients files contained medical assessments (602’s) & current Needs and Service plans per Title 22 regulations within one year.

At approximately 1:00 PM LPA reviewed 5 of 5 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. P&I monies were documented, secure and not commingled. Administrator Certificate for Stacy Anderson #6030360735 Exp. 2/26/2024. Facility is ordering backup generators for entire community.


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 2/28/2024:

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

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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