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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800762
Report Date: 07/24/2023
Date Signed: 07/24/2023 12:48:32 PM

Document Has Been Signed on 07/24/2023 12:48 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 LAMONT HOUSEFACILITY NUMBER:
216800762
ADMINISTRATOR:RAMOS, IANFACILITY TYPE:
735
ADDRESS:816 LAMONT AVETELEPHONE:
(415) 892-1728
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff Member, Abraham GebruTIME COMPLETED:
12:55 PM
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At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Abraham Gebru. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory clients. Upon arrival, LPA was informed that there are 6 clients in care, and all six clients were out of the community attending Day Program. LPA was also informed that there was 1 staff member on site. Associate Director of Residential Services, Stacy Anderson, arrived later during visit at approximately 9:30AM.

At approximately 9:00AM, LPA reviewed the facility's Staff Roster with Staff Member and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 9:15AM, LPA conducted a walk-though of the facility with Staff Member and Assistant Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a two story building with 6 bedrooms, 3 bathrooms, a kitchen, dining room, living room, and 1 staff office room. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

During walk though, LPA observed that one of the client bathrooms had sheet rock exposed and duct tape against the bathtub, and some water damage (See Technical Advisory - Regulation 80088(e)(3)).Per conversation with Associate Director of Residential Services, the duct tape and damage to the wall has been there for a few months. The facility is expecting to replace the bathtub with a shower and repairs are expected to start today, 07/24/2023. LPA obtained pictures and requested that once repair is complete that a picture is sent in to Community Care Licensing (CCL).

LPA also observed that one of the client bathrooms did not have a lid on their trashcan. LPA observed that the trashcan was empty and there was no distinguishable odors in the bathroom. Staff immediately replaced trashcan with one that had a lid.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
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
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 LAMONT HOUSE
FACILITY NUMBER: 216800762
VISIT DATE: 07/24/2023
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Continued from LIC809

The facility's last fire drill was conducted May 2023. Facility's fire extinguishers were last inspected March 2023. Smoke detectors and Carbon Monoxide detectors were tested and operational. During walk through, LPA observed that 1 of 10 Smoke detectors was low on battery. Staff immediately replaced detector.

At approximately 11:00AM, LPA reviewed Client files. LPA reviewed 6 of 6 Client records which were all found to be well organized, thorough and contained the required documentation.

LPA also discussed Administrator paperwork with Associate Director of Residential Services. CCL has paperwork on file for Kate Pokas. The current Administrator for the facility is Ian Ramos. Facility to submit Administrator Paperwork for Ian Ramos to CCL by 08/03/2023.

LPA requested the following Administrator paperwork to update facility file:
Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Advisory) discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
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
LIC809 (FAS) - (06/04)
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