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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801993
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:11:38 PM

Document Has Been Signed on 06/20/2023 01:11 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:CICADA-MILL VALLEYFACILITY NUMBER:
216801993
ADMINISTRATOR:NOEL CAMATOGFACILITY TYPE:
735
ADDRESS:309 ENTERPRISE CONCOURSETELEPHONE:
(415) 888-3880
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 6CENSUS: 6DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Staff Member, Daniel LimpinTIME COMPLETED:
01:20 PM
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Inspection Visit, and met with Staff Member, Daniel Limpin. Administrator, Noel Camatog was unavailable during the visit. The facility provides care to Adults with Developmental and Physical Disabilities and has an approved fire clearance for 6 Non-Ambulatory Clients. Upon arrival, LPA was informed that 5 of 6 clients were out of the community attending Day Program, and that there were 4 staff members on-site.

At approximately 9:30AM, LPA reviewed the facility's staff roster with Staff Member, Daniel Limpin, and found that all staff members on-site were background cleared and associated to the facility per regulation. LPA conducted a walk through of the facility and observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with 6 bedrooms, 3 bathrooms, a kitchen, dining room, living room, and outdoor spaces. Facility has a mitigation plan on file. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to clients. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use.

The facility's last fire drill was conducted May 2023. Facility's fire extinguishers were last inspected March 2023. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods was within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

At approximately 10:00AM, LPA reviewed 6 of 6 Client records which were all found to be well organized, thorough and contained the required documentation. P&I monies were documented, secure and not commingled. At approximately 11:40AM, LPA reviewed medications. All medications were found to be centrally stored and secure.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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: CICADA-MILL VALLEY
FACILITY NUMBER: 216801993
VISIT DATE: 06/20/2023
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Continued from LIC809

At approximately 12:00PM, LPA reviewed 4 staff records. Staff files were all found to have First Aid and CPR certification. All files reviewed were all found to be well organized, thorough and contained the required documentation. Administrator Certificate (6015633735) is current with an expiration date of 04/19/2024. At approximately 12:15PM, LPA conducted interviews.

LPA is requesting the following documents to update the facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Updated Control of Property (Lease)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Affidavit Regarding Client/Resident Cash Resources (LIC 400)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC 9020)
  • Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, July 20, 2023.

No Deficiencies Cited during visit.

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

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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