<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801623
Report Date: 04/18/2023
Date Signed: 04/18/2023 12:35:13 PM

Document Has Been Signed on 04/18/2023 12:35 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 FINE ART STUDIOSFACILITY NUMBER:
216801623
ADMINISTRATOR:YASMIN BOROUMANDFACILITY TYPE:
775
ADDRESS:2 KENSINGTON RD.TELEPHONE:
(415) 453-7099
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 49CENSUS: 33DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Manager Yasmine BoroumandTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hansen conducted an unannounced annual required inspection and met with Program Manager Yasmin Boroumand. There are 33 clients enrolled in the program. The program has 27 clients & 6 staff working at the time of the visit.

LPA toured the facility on 4/18/2023 at 9:15 AM with Program Manager Yasmin Boroumand; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured building and grounds, day activity rooms, kitchen, offices, and bathrooms. Fire extinguishers are fully charged and current while last inspection dated 2/23/2023. Smoke detectors were tested and found to be in working order. Facility has a pull station that is tested by annually. Carbon Monoxide detector was tested. Motor vehicles used to transport clients at the facility and are inspected to ensure safe operating condition by transportation coordinator. Toxins were all safely stored in locked cabinets. Activity rooms had staff supervising art projects. Bathrooms were all equipped with wall mounted soap dispensers and individual paper towels. There is a sufficient supply of sanitary products on hand. Hot water temperature measured 108.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms. Clients provide their own snacks and lunches but program will supply food for special occasions. There is one large refrigerator available for client food storage and another refrigerator for staff. Medication is centrally stored and locked in Program Managers office.

A sample review of five client & five staff records was also completed during the visit on 4/18/2023. LPA reviewed 5 out of 33 client records and found files to be thorough and contain current client care assessments and individualized Service Plans. LPA reviewed five staff records on 4/18/2023 at 11:50 AM and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, training logs are kept for each staff member and were reviewed.



Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CEDARS FINE ART STUDIOS
FACILITY NUMBER: 216801623
VISIT DATE: 04/18/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 LPA was presented with proof of CPR & 1st Aid certification for staff files that were reviewed. P&I is not handled by facility at this time. Disaster Drills are conducted often as required by Title 22 Regulations with last was one on 4/4/2023.
LPA reviewed Licensing Information System (LIS) with Program Manager who stated that all is correct except facility phone number needs to be updated and provided LIC200.

No deficiencies were found in the areas inspected, No citations issued during today’s visit.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 5/2/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2