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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 12/27/2022
Date Signed: 12/27/2022 12:19:00 PM

Document Has Been Signed on 12/27/2022 12:19 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:KEMMETER, FRANKFACILITY TYPE:
735
ADDRESS:1106 FERRIS DR.TELEPHONE:
(415) 892-1208
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:House Manager, Rose CastanedaTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cedars Ferris Drive for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, House Manager, Rose Castaneda, and was granted access into the facility.

LPA and House Manager toured the facility. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were also inspected. Fire Extinguisher was found to be last charged on March 2022 at the time of the inspection. Carbon monoxide detector was operational during inspection. All Smoke Detectors were tested and found to be operational during this inspection. Medication was centrally stored and locked inaccessible to clients in care in the staff office. First aid kit was inspected and found to be appropriate during the inspection. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the inspection. Toxins are stored in a locked cabinet inside the garage and inaccessible to clients in care. Dangerous items were stored inaccessible to clients in care. There was a supply of cleaners, hygiene products and paper products available for clients. Facility hot water temperature in clients' bathroom faucets measured at 115 degrees F in 3 out of 3 faucets and is within Title 22 acceptable regulations of 105 to 120 degrees F. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE. Staff have had all PPE training required and have been N95 Fit tested in 2022.

LPA requested the following documents to be sent to CCL: (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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: CEDARS FERRIS DRIVE
FACILITY NUMBER: 216801291
VISIT DATE: 12/27/2022
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LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
LIC 610D-Emergency Disaster Plan
Updated facility sketch
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

No defiencies were observed or cited during the Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility administrator due to printer issues.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC809 (FAS) - (06/04)
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