<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110625
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:09:13 AM

Document Has Been Signed on 07/24/2023 11:09 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 STREETFACILITY NUMBER:
210110625
ADMINISTRATOR:LEPE, MARIAFACILITY TYPE:
735
ADDRESS:1120 SECOND STREETTELEPHONE:
(415) 898-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Rob Robinson (Director of Residential Services)TIME COMPLETED:
11:24 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) Cuadra arrived unannounced to conduct an Annual Required inspection and met with House Manager Cluvens Deliska. Rob Robinson (Director of Residential Services) arrived later. Clients were attending to Day Program. Required postings were observed. First aid kit was fully stocked.

LPA/staff initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 113.5 and 113.2 which is within regulation of 105 and 120 degrees F. Toxins are locked in a cabinet. Medications are centrally stored in locked office and medication records were reviewed. Three out of three fire extinguishers were charged March 2023, but two out of three lacked a service tag. Smoke detectors and carbon monoxide detector are wired located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 7/10/23. Facility does have a current activity calendar and menu. LPA advised staff to review and ensure one week nonperishable and two days of perishable food supply was available for clients in care (see LIC 9102 TV). Cash resources and documentation were reviewed. However, cash and facility ledgers did not match (see LIC 9102 TV).

At 9:30am LPA conducted a file review of five client and six staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Maria Lepe 6061120735 expired 11/29/23.

Director agreed to submit updates of the following documents by 8/4/23: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), LIC309 Administrative Organization, Surety bond, LIC400 Cash Affidavit for residents.

There are no citations issued during today's inspection. Exit interview conducted with Director and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3