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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 12/30/2021
Date Signed: 12/31/2021 10:22:26 AM

Document Has Been Signed on 12/31/2021 10:22 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:NOVATO RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109022
ADMINISTRATOR:ROBIN HUGHESFACILITY TYPE:
735
ADDRESS:1333 SEVENTH STREETTELEPHONE:
(415) 897-7195
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 15CENSUS: 15DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Robin Hughes - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Robin Hughes. Some clients were present at the facility. Clients at this facility are very independent and there are activities plan for clients during the day if they want to participate.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 12/30/2021 with administrator Robin Hughes facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 09/2021 at the time of the visit. Carbon monoxide detector was operational during visit. Smoke detectors and fire sprinklers are inspected at least annually, and inspection records are going to be submitted to the Department. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside kitchen. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Disaster Drills have been conducted monthly with the last one being conducted on 12/17/2021.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022
VISIT DATE: 12/30/2021
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at facility, small table with hand sanitizer and other items designated for visitors are at entrance. Staff before coming into work has temperature checked. Facility has some PPE supply stored in back hallway closet and office. There has been no new staff hired and 2 new clients since COVID-19. Clients’ medications are stored and locked in medication room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed. Clients have also available zoom and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

There were no deficiencies cited at this time.

LPA Fernandes-Goes is requesting Licensee to update the following documents and submit to the Department by 1/6/2021:

LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 500 Personnel Summary
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC809 (FAS) - (06/04)
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