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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 02/14/2024
Date Signed: 02/14/2024 11:56:59 AM

Document Has Been Signed on 02/14/2024 11:56 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
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:
02/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:House Manager, Brayan ZafraTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:10AM to continue an Annual Required inspection that was initiated on 02/06/2024. LPA was greeted by staff and House Manager, Brayan Zafra, arrived shortly after.

LPA reviewed five staff files including staff training and CPR Certificates. LPA reviewed five client files. Medications and medication records were reviewed. Client cash resources were reviewed. Reviewed files had required documents.

There was one client in care during inspection. LPA observed that the door to the garage was unlocked, as well as the door to the closet in the garage which stores cleaning supplies and chemicals. Drawer storing knives was found to be unlocked at the time of inspection.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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Document Has Been Signed on 02/14/2024 11:56 AM - It Cannot Be Edited


Created By: Helena Rummonds On 02/14/2024 at 11:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CEDARS FERRIS DRIVE
FACILITY NUMBER: 216801291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving the drawer with knives unlocked, as well as the closet that stores toxins unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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House Manager agrees to submit self certification stating that when clients are in care that the toxins and knives will remain locked by POC due date of 02/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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