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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:40:07 PM

Document Has Been Signed on 12/19/2024 03:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NOVATO RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109022
ADMINISTRATOR/
DIRECTOR:		JOHN AHRENSFACILITY TYPE:
735
ADDRESS:1333 SEVENTH STREETTELEPHONE:
(415) 897-7195
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 15CENSUS: 13DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jacquie Burns, House Manager TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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12/19/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 13 clients in care. Facility approved/cleared for 15 ambulatory.

LPA conducted a review of 5 client records. All records had the required documentation.

LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.


LPAs unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to House Manager.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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