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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 02/06/2024
Date Signed: 02/06/2024 01:42:43 PM

Document Has Been Signed on 02/06/2024 01:42 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: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:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:House Manager, Bryan ZafraTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 11:30AM to conduct an Annual Required inspection, as well as follow up on an Incident Report that was received by Community Care Licensing (CCL) on 1/29/2024. Upon LPA arrival, there were no staff or clients in the facility. LPA made phone calls to let the facility know that they arrived, and House Manager, Bryan Zafra arrived shortly after.

LPA and House Manager initiated a tour of the facility around 12:30 PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 132 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. House Manager put in a request with Maintenance to come out to facility to turn down the water heater in order to get within the range allowed per regulation. During walk through of the facility, LPA observed a paint can in the side yard.

Extra hygiene products and linens were available. Cleaning supplies are stored in the garage in a closet. The closet was not locked, however there were no clients in facility at the time of visit. Per conversation with House Manager, before clients arrive back to the facility from day program, the garage is locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the hall closet. Personal Protective Equipment is stored in the office.

Fire extinguishers were last serviced February 2023. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 11/22/2023. LPA reminded House Manager that these are to be conducted on a quarterly basis.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CEDARS FERRIS DRIVE
FACILITY NUMBER: 216801291
VISIT DATE: 02/06/2024
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Continued from LIC809

LPA followed up on an incident report that was received by CCL on 1/29/2024 that described an incident where Client 1 (C1) missed a couple doses of Lorazepam 1mg. Per conversation with House Manager, the pharmacy was in contact with the physician who had not refilled the medication on time, resulting in missed medications. The facility is not responsible for the missed medication.

LPA is unable to complete inspection at this time and will return to complete inspection at a later date. Upon return, LPA will be ensuring that the water temperature has gone down and toxins have been removed from side yard.

No deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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