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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 01/14/2025
Date Signed: 01/14/2025 12:04:19 PM

Document Has Been Signed on 01/14/2025 12:04 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/
DIRECTOR:		KEMMETER, FRANKFACILITY TYPE:
735
ADDRESS:1106 FERRIS DR.TELEPHONE:
(415) 892-1208
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:House Manager, Ian RamosTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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01/14/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 clients in care. Facility approved/cleared for 1 non-ambulatory. Upon arrival, no staff or clients were in the facility. LPA made a phone call to let the facility know they were there. House Manager Ian Ramos arrived shortly after.

At approximately 10:00am, LPA and House Manager toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 107.0 and 116.6 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in the garage and in the kitchen and found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P & I monies were documented. Facility conducts monthly fire and disaster drills.

LPA conducted a review of 4 client records. All records had the required documentation. LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/14/2025 of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400- Affidavit Regarding Client/Resident Cash Resources

Exit interview conducted with House Manager and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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