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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 06/23/2022
Date Signed: 06/23/2022 12:39:28 PM

Document Has Been Signed on 06/23/2022 12:39 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:D STREET RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109691
ADMINISTRATOR:ASHKENAY, REBECCAFACILITY TYPE:
735
ADDRESS:527 D STREETTELEPHONE:
(415) 454-9920
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 10CENSUS: 10DATE:
06/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Counselor, David AndersonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at D Street Residential Support Services unannounced for the purpose of conducting a Plan of Correction (POC) inspection. LPA was met at the door by Counselor, David Anderson, and was granted access into the facility.

During this POC inspection, LPA inspected the bathroom sink. LPA ran the water for approximately five minutes and found that the bathroom sink was free from clogs. LPA observed the water temperature between 105-120 degrees within Title 22 regulation.

No deficiencies observed or cited during this Plan of Correction (POC) inspection. Exit interview was conducted and a copy of this report was signed and given to the Counselor, David Anderson.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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