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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801258
Report Date: 11/04/2025
Date Signed: 11/05/2025 09:11:04 AM

Document Has Been Signed on 11/05/2025 09:11 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/
DIRECTOR:		ANNEKOVA, NATASHAFACILITY TYPE:
775
ADDRESS:72 KENSINGTON RD.TELEPHONE:
(415) 258-2859
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 45CENSUS: 24DATE:
11/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Natasha Annekova, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 11/04/2025, License Program Analyst (LPA) Hansen arrived unannounced at 10:05 AM to conduct a Required 1-year Inspection of the facility. LPA was welcomed by Natasha Annenkova, Program Manager (PM). Day Program has been granted fire clearance of 45 ambulatory clients by Ross Valley Fire Department. There are 24 clients enrolled in the program and had 19 clients & 6 staff working at the time of the visit.

LPA toured facility at 10:10 AM with PM Natasha Annenkova. 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 2/5/2025. 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 113.1 degrees F, within Title 22 regulation of 105 to 120 degrees F. West bathroom has unsteadied (pulling out of wall) handrail at toilet, serving as additional equipment/aid for the convenience of accommodating clients (see LIC 9102 TA). PM indicated maintenance to fix 11/5/2025. Disaster Drills are conducted quarterly with the last one being conducted on 10/21/2025. 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, Marin Civic Center Grounds, and the nursery. In addition, music, drumming and art classes are offered at the program.

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NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/04/2025
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...Continued from 809

At 10:30AM LPA reviewed five (5) clients & five (5) staff records. Five (5) of five (5) clients records were observed to be current, including: admission agreement; personal rights; health screening & care plan. Five (5) of five (5) 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 11/18/2025:

LIC 309 Administrative Organization (indicates 3 yr term of offices)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Clients

No deficiencies cited during today's visit. Exit interview conducted. Copy of report and LIC9102 (Technical Violation/Advisory) discussed and provided to Program Manager. Exit interview conducted. Copy of report discussed and provided to PM. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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