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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801623
Report Date: 04/19/2022
Date Signed: 04/19/2022 11:23:54 AM

Document Has Been Signed on 04/19/2022 11:23 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CEDARS FINE ART STUDIOSFACILITY NUMBER:
216801623
ADMINISTRATOR:YASMIN BOROUMANDFACILITY TYPE:
775
ADDRESS:2 KENSINGTON RD.TELEPHONE:
4154537099
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 49CENSUS: 31DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brenda Dahl Human Resorses GeneralistTIME COMPLETED:
11:23 AM
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Licensing Program Analyst (LPA) Hansen arrived to conduct an unannounced annual 1-Yr Infection Control inspection of Cedars Fine Art Studios ADP. LPA was welcomed by staff Laura Alders and informed Program Manager Yasmin Borouman was out for the day. LPA met with Human Resource Generalist Brenda Dahl. There are 51 clients enrolled in the program. Director of HR Dorreen Roth arrived at facility at end of tour and signed annual. The program has 31 clients & 9 staff working at the time of the visit.

LPA toured the facility on April 19, 2022 at 9:15 AM with Human Resources Generalist, Brenda Dahl; facility was found to be clean and at a comfortable temperature. LPA toured building and grounds, day activity rooms, kitchen, and bathrooms. Fire extinguishers are fully charged and current while last inspection dated for January 25, 2022. Facility has a pull up station that is tested by annually. Motor vehicles used to transport clients at the facility and are inspected to ensure safe operating condition by transportation coordinator. Hazardous toxins were locked and stored properly. Bathrooms were all equipped with wall mounted soap dispensers and individual paper towels. Knives and metal utensils were locked in the kitchen at the time of the inspection. There is a sufficient supply of sanitary products on hand. Hot water temperature measured 120 degrees within Title 22 acceptable regulation of 105 to 120 degrees in bathrooms. Clients provide their own snacks and lunches, but the program will supply food for special occasions. There is one large refrigerator available for client food storage and another refrigerator for staff. Facility does not administer medications.

Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 7/14/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in storage closet down southside bldg. hall from main office. Staff had all PPE training required as well have been N95 Fit Tested. All staff have been fully vaccinated and received their COVID booster shots.


Continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 3
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 FINE ART STUDIOS
FACILITY NUMBER: 216801623
VISIT DATE: 04/19/2022
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LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1st Aid certification for staff.

There were no deficiencies cited at this time.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/29/2022:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan
LIC400-Affidavit Regarding Client Cash Resources
LIC 9020 – register of Facility Client’s
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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