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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110627
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:44:46 PM

Document Has Been Signed on 06/12/2024 02:44 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CEDARS BROWN DRIVEFACILITY NUMBER:
210110627
ADMINISTRATOR/
DIRECTOR:		LEPE, MARIAFACILITY TYPE:
735
ADDRESS:6 BROWN DRIVETELEPHONE:
(415) 892-1421
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 4DATE:
06/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Adminstrator, Maria LepeTIME VISIT/
INSPECTION COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:30PM to continue an Annual Required Inspection that was initiated on 05/24/2024. LPA was greeted by Administrator, Maria Lepe. LPA and Administrator discussed the purpose of the visit.

LPA reviewed 2 staff files. Staff files contained all required documents. Medications and medication records were reviewed. Medications were documented as per regulation. Client cash resources were reviewed. Cash resources were documented as per regulation.

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 1