210110625-5-4-2022-21-AS-CFGS-CE4MUY-20220504095556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210110625
Report Date: 05/04/2022
Date Signed: 05/04/2022 09:57:02 AM

Document Has Been Signed on 05/04/2022 09:57 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CEDARS SECOND STREET		FACILITY NUMBER:	210110625
ADMINISTRATOR:	LEPE, MARIA		FACILITY TYPE:	735
ADDRESS:	1120 SECOND STREET		TELEPHONE:	(415) 898-5525
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 6		CENSUS: 5	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Lepe - Administrator		TIME COMPLETED:	09:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator Maria Lepe. Clients were in an outing with staff and day program. Per staff 4 clients are going into day program depending on the day of the week. There are activities planned for clients during the day if they want to participate. LPA arrived at the facility and observed a check in for staff and visitor’s by the entrance door outside. During facility tour on 5/4/2022 with administrator Maria Lepe facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 03/2022 at the time of the visit. Carbon monoxide detector and sample smoke detectors test was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked laundry room in the hallway. LPA observed that dangerous items were locked. There was a supply of cleaners, hygiene products and paper products available for clients. Sample of client’s bedrooms were inspected and had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 109.9 degrees F and 115.5 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted every month with the last one being conducted on 4/27/2022. Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CEDARS SECOND STREET	FACILITY NUMBER: 210110625
	VISIT DATE: 05/04/2022

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Infection Control:
Facility has submitted a COVID-19 mitigation program plan that has been approved. Posters have been placed at facility, container with hand sanitizer and other items designated for visitors and staff are at entrance. Staff before coming into work has temperature checked. Facility has some PPE supply stored in the garage area and main corporation office. There has been no new staff hired and/or new clients since last year’s visit. Clients’ medications are stored and locked in medication cabinet in a locked office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility with exception of one client do to the client's need, however; staff stated that they are able to wear masks when going on outings and all clients are encourage to wear masks. Staff had masks on during this visit. Clients have available virtual and telephone calls when contacting with family members and others. Per staff all PPE training required is on file and staff has acquired N-95 fit testing.

There were no deficiencies cited at this time.

Department is requesting Licensee to update the following documents and submit to CCL by 5/11/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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