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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:33:13 PM

Document Has Been Signed on 07/27/2023 03:33 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:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Team Leader, Chris SpeedTIME COMPLETED:
03:40 PM
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At approximately 1:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Team Leader, Chris Speed. Program Director, Jennifer Lanciault, arrived at approximately 1:40PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance for 10 Ambulatory Clients with a total capacity for 10 Clients. Upon arrival, LPA was informed that there were 10 clients in care, and 3 clients were out of the community. LPA was also informed there were currently 3 staff members on site.

At approximately 1:20PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:25PM, LPA conducted a walk-though of the facility with Team Leader. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 3 story building with 5 Client bedrooms, 1 staff room, 2 staff offices, 4 bathrooms, a kitchen, dining room, living room, and laundry area. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

During walk-through LPA observed that facility's Fire extinguishers were last inspected April 2022. Per conversation with Program Director, Fire Extinguishers are scheduled to be re-inspected next week. During visit, Smoke detectors and carbon monoxide detectors were observed to be last tested May 2023. The facility's last fire drill was conducted July 2023.

LPA 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 Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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