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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110627
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:20:50 PM

Document Has Been Signed on 07/20/2023 02:20 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:CEDARS BROWN DRIVEFACILITY NUMBER:
210110627
ADMINISTRATOR:LEPE, MARIAFACILITY TYPE:
735
ADDRESS:6 BROWN DRIVETELEPHONE:
(415) 892-1421
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maria Lepe, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required inspection to this facility and was welcome by and met with House Manager Maria Lepe, Clients were attending their day programs at the time of the visit. There are 5 clients in the facility.

LPA toured the facility on 7/20/2023 at 1:15 PM with House Manager, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 3/2/2023 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 116.2 degrees F and 117.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 client’s bathroom while touring facility on 7/20/2023 at 1:45 PM. 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 cabinet inside the facility garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads as required by Title 22 Regulations # 85088(c)(4) on 7/20/2023 at 2:00 PM with exception of four client’s bed. Facility to ensure that all client’s beds have mattress pads unless client refuses to use it.
LPA was unable to complete inspection and will return at a later date to conduct client & staff file review, medication review, and check P & I monies.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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