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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801935
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:52:52 AM

Document Has Been Signed on 09/17/2024 11:52 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAMBRIDGE HOUSEFACILITY NUMBER:
216801935
ADMINISTRATOR/
DIRECTOR:		LAKEDA BROWN-STEWARDFACILITY TYPE:
735
ADDRESS:1420 CAMBRIDGE STREETTELEPHONE:
(415) 898-4262
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Kayla Hotchkiss (Manager), Nor (Staff Member)TIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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09/17/2024, 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 five(5) clients in care. All clients were at day care upon arrival.

At approximately 9:30am, LPA and Staff 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 being labeled and dated. Backyard area has a pool with a gated fence, that was found to be locked and secured. At approximately 10:00am Kayla (Manager) showed up during visit.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and 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 111 degrees F within the range of 105 to 120 degrees F. Fire extinguishers were last inspected November, 2023. 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 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, secure and not commingled.

At approximately 10:30 am, LPA conducted a review of five client records. All records had the required documentation.

continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAMBRIDGE HOUSE
FACILITY NUMBER: 216801935
VISIT DATE: 09/17/2024
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At approximately 10:50 am, LPA conducted review of five 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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report (Updated)
LIC308- Designation of Responsibility
LIC402- Surety Bond
LIC400- Affidavit regarding Client/Resident Cash Resources
LIC9020- Register of Clients/Residents

Exit interview conducted with Manager and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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