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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:58:39 AM

Document Has Been Signed on 08/08/2024 10:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:D STREET RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109691
ADMINISTRATOR/
DIRECTOR:		ASHKENAY, REBECCAFACILITY TYPE:
735
ADDRESS:527 D STREETTELEPHONE:
(415) 454-9920
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 10CENSUS: 7DATE:
08/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Team Lead, Zasha DeaepTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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At approximately 9:10AM, Licensing Program Analysts (LPAs) Loera and Felias arrived unannounced to continue a Required 1 Year visit and met with Team Leader, Zasha Deaep. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 10 Ambulatory Clients. Upon arrival, LPAs were informed that there were 7 clients in care and 1 staff member on-site.

LPA's reviewed staff files and client medication. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Team Leader. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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