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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 10/06/2021
Date Signed: 10/06/2021 10:07:57 AM

Document Has Been Signed on 10/06/2021 10:07 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:D STREET RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109691
ADMINISTRATOR:STEFEN HAINBUCHFACILITY TYPE:
735
ADDRESS:527 D STREETTELEPHONE:
(415) 454-9920
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 10CENSUS: 8DATE:
10/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mental Health Counselor, Charles BoomerTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at D Street Residential Support Services for the purposes of conducting an Unannounced Case Management-Incident inspection. LPA met with, Mental Health Counselor, Charles Boomer and was granted access into the facility.

LPA toured the facility and found the facility to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. During the Case Management-Incident inspection, LPA requested the following documents:

-LIC 500
-Medication Assessment Record (MAR)
-Client roster list
-Staff training records
-Progress notes

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report will be emailed to the Administrator, Rebecca Ashkenazy.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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