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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800762
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:53:13 PM

Document Has Been Signed on 08/08/2023 03:53 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:
08/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Staff Member, Abraham Gebru, and House Manager, Ronald BerlinerTIME COMPLETED:
04:00 PM
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At approximately 2:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Abraham Gebru. House Manager, Ronald Berliner, arrived to the facility at approximately 2:53PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 6 clients in care, and all six clients were out of the Facility attending Day Program. LPA was also informed that there one staff member on-site.

At approximately 2:20PM, LPA reviewed 6 Client Medication Records and P&I Monies. 5 of 6 Medication records were observed to be centrally stored and secure. 1 of 6 Client Medication Records was found to not have a discontinued order for one medication and it has not been administered to the client for at least 3 months. Per Per Title 22 Regulation, there is to be written instructions from a Physician in the event a medication is discontinued as well as a medical re-evaluation conducted for the client (See Technical Advisory 80075(b)(5)(A). Client P&I monies were documented, secure and not commingled.

At approximately 2:55PM, LPA reviewed a sample size of 3 Staff Files. Review of Staff Files indicated that staff had First Aid and CPR certification.

LPA observed that the facility does not have a evacuation chair at this time. Facility does have an operable lift. House Manager understands that an evacuation lift needs to be on-site to remain compliant with Health and Safety Code (See Technical Advisory 1565(f)(1).

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Advisories) discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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