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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800847
Report Date: 02/11/2025
Date Signed: 02/11/2025 11:40:51 AM

Document Has Been Signed on 02/11/2025 11:40 AM - 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 WALTER HOUSEFACILITY NUMBER:
216800847
ADMINISTRATOR/
DIRECTOR:		STACY ANDERSONFACILITY TYPE:
735
ADDRESS:1842 NOVATO BLVDTELEPHONE:
(415) 892-1073
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Frank KenmeterTIME VISIT/
INSPECTION COMPLETED:
11:55 PM
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02/11/2025, Licensing Program Analysts (LPAs) Loera and Stevenson conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required and conduct monthly disaster drills Facility has an infection control plan as required. There are currently 5 clients in care. LPAs upon arrival were greeted by administrator Frank Kenmeter and 1 client was present during inspection.

At approximately 9:45am, LPAs and administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner. House has 2 emergency generators available.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 117.7 degree and 119.6 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were centrally locked and stored. LPAs conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P & I monies were documented. Facility conducts monthly fire and disaster drills with the last drill performed January 2025.

Facility was noted to have copious engaging activities for clients including, music, crafts, coloring, exercise, day trips etc.
Facility has a large covered deck for dinning and various activities.

LPAs conducted a review of 5 client records. All records had the required documentation. LPAs conducted review of 4 staff records/training. Upon a review of staff records, LPAs found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CEDARS WALTER HOUSE
FACILITY NUMBER: 216800847
VISIT DATE: 02/11/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/11/2025 of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400- Affidavit Regarding Client/Resident Cash Resources
Infection control plan (review and update if needed)
Emergency/disaster plan (review and updated if needed)

Exit interview conducted with administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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