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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801258
Report Date: 12/30/2021
Date Signed: 12/30/2021 12:20:08 PM

Document Has Been Signed on 12/30/2021 12:20 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:COMMUNITY CONNECTIONSFACILITY NUMBER:
216801258
ADMINISTRATOR:ANNEKOVA, NATASHAFACILITY TYPE:
775
ADDRESS:72 KENSINGTON RD.TELEPHONE:
(415) 258-2859
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 45CENSUS: 30DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Natasha Annekova - AdministratorTIME COMPLETED:
12:20 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year visit of the facility. LPA was welcomed by Natasha Annekova, Administrator. There are 30 clients enrolled in the program. The program has 20 clients & 8 staff working at the time of the visit.

LPA toured the facility on December 10, 2021 at 10:45 AM with Administrator Natasha Annekova; facility was found to be clean and at a comfortable temperature. LPA toured building and grounds, day activity rooms, kitchen, and bathrooms. Fire extinguishers are fully charged and current while last inspection dated for February 19, 2021. Smoke detectors and carbine monoxide detectors were tested and in working condition. Motor vehicles used to transport clients at the facility are inspected to ensure safe operating condition by transportation coordinator. Hazardous toxins were locked and stored properly in hallway closet. Bathrooms were all equipped with wall mounted soap dispensers and individual paper towels. Knives and metal utensils were locked in the office at the time of the inspection. There is a sufficient supply of sanitary products on hand. Hot water temperature measured 114 degrees F. and 116.9 degrees F. within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms. Clients provide their own snacks and lunches, but the program will supply food for special occasions. There is one large refrigerator available for client and staff food storage. Facility doesn’t administer medications.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: COMMUNITY CONNECTIONS
FACILITY NUMBER: 216801258
VISIT DATE: 12/30/2021
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Infection Control:

Facility has submitted a mitigation program plan that has been approved, 12/7/2021. All staff, clients, & visitors check in with the electronic temperature log and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in closet in staff office with emergency supplies. Staff had all PPE training required on file as well have been N95 Fit Tested.



Disaster Drills are conducted monthly with the last being 11/2021.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA discussed new PIN 21-44 that went into effect Nov. 30, 2021 regarding all staff needing to be fully vaccinated or have exemption letter on file with results of their weekly surveillance testing.

LPA was presented with proof of CPR & 1st Aid certification for staff.


No deficiencies cited during this visit in the areas inspected.

LPA Hansen is requesting Licensee to update and submit the following documents by 1/29/2022 to RPRO:



LIC308-Designation of Facility Responsibility
LIC500-Personnel Report
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC809 (FAS) - (06/04)
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