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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 11/19/2021
Date Signed: 11/19/2021 12:53:43 PM

Document Has Been Signed on 11/19/2021 12:53 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, 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: 9DATE:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Interim Administrator, Rebecca NewtonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at D Street Residential Support Services for the purpose of conducting a Case Management-Incident Inspection. LPA was met at the door by interim Administrator, Rebecca Newton and was granted access into the facility.

Licensing Program Analyst (LPA), Farhaan Sarangi conducted a Case Management inspection today to address three (3) Special Incident Reports dated; 11/12/2021 and submitted by facility staff and two (2) SOC 341s dated for the same date. LPA conducted interviews with staff, clients and the assigned Social Worker for C1 that was also present at the facility.

Exit interview was conducted, and a copy of this report was emailed to the facility Assistant Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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