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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800419
Report Date: 12/22/2022
Date Signed: 12/22/2022 01:16:26 PM

Document Has Been Signed on 12/22/2022 01:16 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:HICKORY HOUSEFACILITY NUMBER:
216800419
ADMINISTRATOR:BROWN-STEWARD, LAKEDAFACILITY TYPE:
735
ADDRESS:426 HICKORY LANETELEPHONE:
(415) 472-7204
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lead Staff, Danny MclaneTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/22/2022 to conduct a required 1-year inspection. This inspection was focused on the infection control practices and procedures of this facility. LPA conducted inspection with lead staff, Danny Mclane. Administrator was notified of LPA arrival.

LPA observed necessary COVID postings and screening materials at the front entrance. LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. LPA observed sufficient perishable and non perishable food. Medications were locked and secured. Toxins were locked and secured. Clients attend day programs. Staff will encourage clients to practice good mask etiquette. There were extra hygiene supplies and fresh linens available for clients. Fire extinguishers inspected were charged and current. Carbon monoxide detectors were present. Staff monitor clients for symptoms. Staff have been provided with infection control training. LPA observed Personal Protective Equipment available to support a client in isolation.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection:

LIC500 Personnel Report
LIC308 Designation of Responsibility
LIC610D Disaster Plan
LIC400 Affidavit Regarding Client Cash Resources
LIC 402 Surety Bond

Exit interview conducted with staff and a copy of this report emailed to the administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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