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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801258
Report Date: 01/27/2025
Date Signed: 01/27/2025 12:41:17 PM

Document Has Been Signed on 01/27/2025 12:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COMMUNITY CONNECTIONSFACILITY NUMBER:
216801258
ADMINISTRATOR/
DIRECTOR:		ANNEKOVA, NATASHAFACILITY TYPE:
775
ADDRESS:72 KENSINGTON RD.TELEPHONE:
(415) 258-2859
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 45CENSUS: 21DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Natasha Annekova, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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On 1/27/2025, License Program Analyst (LPA) Robert Frank arrived unannounced at 9:10 AM to conduct a Required 1-year Inspection of the facility. LPA was welcomed by Natasha Annekova, Program Manager (PM). There are 30 clients enrolled in the program and had 21 clients & 5 staff working at the time of the visit.
LPA toured facility at 9:35 AM with PM 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 were observed to be charged with last inspection dated was May 2, 2023. Fire extinguishers are required to be inspected annually. A Technical Violation was issued for the fire extinguishers inspection to be past due. 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 110.9 degrees F. and 111.2 degrees F. which is within Title 22 regulation of 105 to 120 degrees F. Disaster Drills are conducted quarterly with the last one being conducted on 11/18/2024. 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 food bank, Marin Headlands and the nursery. In addition, music, drumming and art classes are offered at the program.

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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: COMMUNITY CONNECTIONS
FACILITY NUMBER: 216801258
VISIT DATE: 01/27/2025
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...Continued from 809

At 10:25 AM LPA reviewed five (5) clients & six (6) staff records. Five (5) of five (5) clients records were observed to be current, including: admission agreement; personal rights; health screening & care plan. Six (6) of six (6) staff records reviewed were current including required training's, health screening and valid 1st Aid & CPR certification.

The Following Items are to be submitted to CCLD by DOB 2/27/2025:

LIC 308 Designated Facilty Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Clients

No deficiencies cited during today's visit. Exit interview conducted. Copy of report and LIC9102 (Technical Violation/Advisorie) discussed and provided to Administrator. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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