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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801258
Report Date: 12/19/2023
Date Signed: 12/19/2023 01:48:41 PM

Document Has Been Signed on 12/19/2023 01:48 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: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: 28DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Natasha Annekova, Program ManagerTIME COMPLETED:
02:00 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Inspection of the facility. LPA was welcomed by Natasha Annekova, Program Manager. There are 28 clients enrolled in the program. The program had 20 clients & 5 staff working at the time of the visit, 16 clients had been picked up at time of inspection to go out into the community.

LPA toured facility on 12/19/2023 at 9:30 AM with Program Manager Natasha Annekova; facility was found to be clean and at a comfortable temperature, all walkways and exits were free of obstructions. Tour consisted of building and grounds, day activity rooms, kitchen, and bathrooms. Fire extinguishers are sufficiently charged with last inspection dated was May 21, 2023. Smoke detectors and carbine monoxide detectors were tested and in working condition. Motor vehicles used to transport clients at 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. There is a sufficient supply of sanitary products on hand. Hot water temperature measured 114.4 degrees F. and 111 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 refrigerator available for client and staff food storage. Facility does not administer medications or handle clients’ money. Facility has weekly outings of horseback riding, miniature farm sanctuary, and volunteer work at Marin Headlands and the nursery weekly as well offers music, drumming and art classes at the program.

A review of five clients & five staff records was conducted. LPA reviewed resident’s files at 10:30 AM and learned that 5 of 5 clients records were found to be current, including: admission agreement; personal rights; health screening & care plan.



Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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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: 12/19/2023
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LPA reviewed a sample of staff records at 12:15 PM and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Staff records reviewed were current including required training's & health screening. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed.

LPA reviewed Licensing Information System (LIS) with Program Director who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills are conducted monthly with the last one being conducted on 11/30/2023.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 1/8/2024:



LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Clients
Copy of Control of Property/Updated Lease
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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