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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801258
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:13:26 AM

Document Has Been Signed on 12/06/2022 11:13 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 31DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Natasha Annekova - AdministratorTIME COMPLETED:
11:15 AM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility. LPA was welcomed by Natasha Annekova, Administrator. There are 31 clients enrolled in the program. The program has 20 clients & 6 staff working at the time of the visit. LPA is also looking into a self reported incident dated 11/30/2022 received in by Community Care Licensing (CCL) on 12/05/2022.

LPA toured the facility at 9:30 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 sufficiently charged although last inspection dated was February 19, 2021. Maintance of buildings (although this program only uses a portion of the building) has scheduled inspection of extinguishers and LPA has given TA. 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 113.5 degrees F. and 120 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 or handle clients’ money. Facility has weekly outings of horseback riding, and volunteers work at Marin Headlands and the nursery weekly as well offers music and art classes at the program weekly.
Infection Controle:

Facility has submitted a mitigation program plan and Infection Control Plan. 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.



Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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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: COMMUNITY CONNECTIONS
FACILITY NUMBER: 216801258
VISIT DATE: 12/06/2022
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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 was presented with proof of CPR & 1st Aid certification for staff.

Disaster Drills are conducted monthly with the last being 10/11/2022.

No deficiencies cited during this visit in the areas inspected.

LPA conducted interviews regarding SOC 341 incident of 11/30/2022 and gathered files.

LPA Hansen is requesting Licensee to update and submit the following documents by 12/20/2022 to SRRO:



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

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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