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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110627
Report Date: 07/25/2023
Date Signed: 07/25/2023 02:59:24 PM

Document Has Been Signed on 07/25/2023 02:59 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:
07/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Maria Lepe, AdministratorTIME COMPLETED:
03:15 PM
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
License Program Analyst (LPA) Shannan Hansen arrived at 1:30 PM to complete an unannounced annual inspection and met with Maria Lepe, House Manager. There is a total of 5 residents.

LPA reviewed Client and Staff records and centrally stored medication record, to complete this annual inspection.

A review of five clients and a sample review of two staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 1:35 PM on 7/25/2023 and learned that 5 of 5 clients have an updated reappraisal/needs & care plan and physician’s report. P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingle, and ledgers are current on 7/25/2023 at 1:50 PM.



Medications were centrally stored in a locked filed cabinet of facility office on 7/25/2023. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 7/25/2023 at 2:15 PM. Centrally Stored Medication Records (CSMR) on 7/25/2023 at 2:15 PM were currently for 2 out of 2 clients in the facility.

LPA conducted a sample review of staff records at 2:30 PM on 7/25/2023 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of CPR & 1st Aid certification for staff records that were reviewed. Maria Lepe Administrator Certificate # 6061120735 expires on 11/29/2023.

Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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
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 BROWN DRIVE
FACILITY NUMBER: 210110627
VISIT DATE: 07/25/2023
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
26
27
28
29
30
31
32
LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time other than facility email that will need to be changed. Disaster Drills have been conducted often with the last one being conducted 6/2023.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 8/22/2023 to SRRO:

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 qualifications and Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3