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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801935
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:47:01 PM

Document Has Been Signed on 02/16/2023 03:47 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:CAMBRIDGE HOUSEFACILITY NUMBER:
216801935
ADMINISTRATOR:DONNABELL GALICIAFACILITY TYPE:
735
ADDRESS:1420 CAMBRIDGE STREETTELEPHONE:
(415) 898-4262
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
02/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Staff Member Zayde Massoud, and Administrator, Lakeda Brown-StewardTIME COMPLETED:
03:55 PM
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At approximately 1:25PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management Incident visit and met with Staff Member, Zayde Massoud. Administrator, Lakeda Brown-Steward arrived later during visit at approximately 2:05PM. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

LPA reviewed the following reports with Administrator:



Incident Report 1: CCL received an incident report on 12/28/2022. Report states that on 12/25/2022, Client 1 (C1) returned from a family home visit and was observed to have missing medications. Per review of client records, C1 is unable to take medications without supervision. Per conversation with Administrator, C1 was in the care of their family when the medication error occurred.

Incident Report 2: CCL received an incident report on 1/25/2023. Report states that on 1/22/2023, Client 2 (C2), exited the facility and was followed by staff. A member of the community observed C2 fall and contacted Emergency Personnel. Staff met C2 at the hospital. Per review of client records, C2 is unable to leave the facility without supervision. Per conversation with Administrator, C2 has been doing well since their return to the facility.

LPA and Administrator discussed the following:
  • Covid and Influenza A Protocols
  • Staffing Resources and Staff Training
  • Incident/Death Reports and Reporting Requirements
  • Annual Inspection Expectations


Continued on LIC809
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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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: CAMBRIDGE HOUSE
FACILITY NUMBER: 216801935
VISIT DATE: 02/16/2023
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Continued from LIC 809

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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