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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801623
Report Date: 04/25/2024
Date Signed: 04/25/2024 11:33:02 AM

Document Has Been Signed on 04/25/2024 11:33 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/
DIRECTOR:		YASMIN BOROUMANDFACILITY TYPE:
775
ADDRESS:2 KENSINGTON RD.TELEPHONE:
(415) 526-1350
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 49CENSUS: 35DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Yasmin Boroumand, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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LPA Hansen conducted an unannounced annual required inspection and met with Program Manager Yasmin Boroumand. There are 35 clients enrolled in the program. The program has 26 clients & 9 staff working at the time of the visit.

LPA toured the facility on 4/25/2024 at 9:10 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 2/12/2024. Smoke detectors were tested and found to be in working order. Facility has a pull station that is tested bi-annually. Carbon Monoxide detector was tested and working. Toxins and cleaning supplies are stored in supply room closet that was found open during tour on 4/25/2024 at 9:26am (see pic & LIC809-D) Program Director closed and locked door and advised staff to keep it locked. 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 between 110.4 degrees F & 120.7 degrees F in 2 of 2 bathrooms used by clients. Day program is having one hot water heater turned down. 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.

A sample review of five client & five staff records was also completed during visit on 4/25/2024. LPA reviewed 5 out of 35 client records and found files to be thorough and contain current client care assessments and individualized Service Plans. LPA reviewed five staff records on 4/25/2024 at 10:50 AM and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions.



Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 11:33 AM - It Cannot Be Edited


Created By: Shannan Hansen On 04/25/2024 at 11:06 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 FINE ART STUDIOS
FACILITY NUMBER: 216801623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which 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 LPA & Programs Direcots observation during tour, the licensee did not comply with the section cited above with closet containing cleaning supplies and toxic chemicals was left open and accesible to clients which poses/posed a potential health, safety or personal rights risk to persons in care. Program Director closed & locked.
POC Due Date: 05/16/2024
Plan of Correction
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Program Director agrees to conduct an inservice training with all staff during safety briefing meetings to remind them to ensure all items that could pose danger are inaccessible to clients. Program Director to submit proof of training with staff signatures & dates to CCL by POC date of 5/16/2024
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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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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: 04/25/2024
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LPA was presented with proof of CPR & 1st Aid certification for staff files that were reviewed. There are no medications for clients kept at this time at the program. 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 12/13/2023.

Program Director supplied requested annual documents at visit.

Appeal Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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