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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110625
Report Date: 08/25/2021
Date Signed: 08/27/2021 09:39:46 AM

Document Has Been Signed on 08/27/2021 09:39 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:CEDARS SECOND STREETFACILITY NUMBER:
210110625
ADMINISTRATOR:GALANG, MAYEENFACILITY TYPE:
735
ADDRESS:1120 SECOND STREETTELEPHONE:
(415) 898-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
08/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Maria Lepe - House ManagerTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with Maria Lepe - House Manager. The purpose of the case management visit was to obtain additional information regarding incident report & SOC 341 Suspect Abuse that occurred on 7/20/2021 for resident C1 - facility reported to the Department on 7/21/2021.

LPA interviewed Maria Lepe House Manager, acquired more information and discussed regarding incident. Per house manager, staff S1 was let it go in the same day of the incident and no longer works for the corporation. LPA advised facility program manager to conduct a personal rights review training and talk with staff regarding feeling burned out and/or need of a day off. (see LIC 812) In addition, LPA acquired documentation related to the staff involved.


No deficiencies cited during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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