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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 01/21/2022
Date Signed: 01/21/2022 12:44:03 PM

Document Has Been Signed on 01/21/2022 12:44 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:CEDARS FERRIS DRIVEFACILITY NUMBER:
216801291
ADMINISTRATOR:ANDERSON, STACYFACILITY TYPE:
735
ADDRESS:1106 FERRIS DR.TELEPHONE:
(415) 892-1208
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
01/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Care Giver, Viviane LundyTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cedars Ferris Drive for the purpose of conducting a Case management incident inspection. LPA Sarangi met with Care Giver, Viviane Lundy, and was granted access into the facility.

During the Case Management incident inspection, LPA advised that the Department is looking into an incident that was reported via a SOC341. LPA interviewed Client #1, #2 and #3. In addition, LPA conducted an interview with Staff Member #2 (S2). LPA requested contact information for Staff Member #1 (S1).

No deficiencies observed or cited during this Case management incident inspection. Exit interview was conducted and a copy of this report will be emailed to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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