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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801935
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:38:08 AM

Document Has Been Signed on 03/13/2023 11:38 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:CAMBRIDGE HOUSEFACILITY NUMBER:
216801935
ADMINISTRATOR:LAKEDA BROWN-STEWARDFACILITY TYPE:
735
ADDRESS:1420 CAMBRIDGE STREETTELEPHONE:
(415) 898-4262
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
03/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Lakeda Brown-StewardTIME COMPLETED:
11:45 AM
NARRATIVE
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Staff Member, Imani Lovings and Nor Bouzraa. Administrator, Lakeda Brown-Steward, arrived later during visit at approximately 10:45AM. During a visit conducted on 2/16/2023, interviews conducted with staff revealed that the incident report provided to Community Care Licensing (CCL) was inaccurate. LPA received a revised and accurate report on 2/17/2023. The purpose of today's visit is to follow up on this new self-reported incident that was submitted to CCL.

Incident Report #1: CCL received an incident report on 2/17/2023. Report states that on 1/22/2023, staff observed the facility's backdoor open. Staff observed that Client 1 (C1), was not in the home. Staff immediately started searching for C1 and notified Emergency Personnel, and Management. C1 was found by Emergency Personnel and taken to the hospital. Staff met C1 at the hospital and took them home once it was determined that C1 was able to return to the facility. Per review of client records, C1 is unable to leave the facility without supervision.

Per conversation with Administrator, C1 has been doing well since their return to the facility. Facility plans to install an alarm system to alert staff of any exit-seeking behaviors by Clients.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted. Copy of report, LIC-809D, LIC 811 (Confidential Names), Plan of Corrections, and Appeal Rights 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: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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Document Has Been Signed on 03/13/2023 11:38 AM - It Cannot Be Edited


Created By: Caitlynn Felias On 03/13/2023 at 10:48 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: CAMBRIDGE HOUSE
FACILITY NUMBER: 216801935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement has not been met as evidenced by: Based on Review of Client Records, the Licensee did not
comply with the section cited above. Records state that Client is unable to leave facility
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Licensee to submit Self Certification Statement to CCL. Certification to state facility's plan of installing an alarm system for facility exit doors by 3/14/2023. Licensee to update CCL with a timeline that includes installation and completion dates once determined. Licensee to notify CCL of any updates or delays regarding installation of system. Licensee to submit
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without staff supervision. This poses an immediate health and safety risk to Clients in Care.
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receipt of installation and/or photographs as proof of completion to CCL.

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


LIC809 (FAS) - (06/04)
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