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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:26:47 PM

Document Has Been Signed on 12/20/2022 01:26 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: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: DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Robin Hughes, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa 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.

During facility tour on 12/20/2022 with administrator Robin Hughes facility was found to be a comfortable temperature with all exits free from obstruction. Sample of clients' bedrooms, common areas, kitchen & food storage areas were inspected and found to be clean and organized. Two carbon monoxide detectors were operational during visit. Smoke detectors and fire sprinklers are inspected at least annually: last visit was 4/19/22. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the 3 refrigerators was 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. All bathrooms had signs for hand washing, a supply of soap and paper towels, and were clean and operational, although Bathroom #1 needs some floor repairs. Clients' bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Emergency/Fire Drills have been conducted monthly with the last one being conducted on 11/18/2022.

Infection Control:
Facility has submitted a Mitigation Program Plan and Infection Control Plan. Posters have been placed at the entrance to the facility, small bag with hand sanitizer and thermometer designated for visitors are at entrance. Most meetings are done outside as much as possible. Facility has PPE supply stored in back hallway closet and office. Clients’ medications are stored and locked in medication room. Facility has a 30-day supply of medication for clients. Clients are encouraged to wear masks inside the facility, and 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.
There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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