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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801993
Report Date: 06/21/2024
Date Signed: 06/21/2024 02:18:37 PM

Document Has Been Signed on 06/21/2024 02:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CICADA-MILL VALLEYFACILITY NUMBER:
216801993
ADMINISTRATOR/
DIRECTOR:
NOEL CAMATOGFACILITY TYPE:
735
ADDRESS:309 ENTERPRISE CONCOURSETELEPHONE:
(415) 888-3880
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Noel CamatogTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Administrator, Noel Camatog, arrived shortly after.

LPA and Administrator initiated a tour of the facility around 10:00 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 106 and 109 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Staff confirmed that on Fridays they go grocery shopping. Medications were centrally stored and locked. Emergency food and water is stored in the pantry.


Fire extinguishers were last serviced March 08, 2024. Facility has combination smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted June 7, 2024.

Client cash resources were reviewed. Facility was over the limit listed on their LIC400 (Affidavit Regarding Client Cash Resources). LPA and Administrator discussed that they must update their LIC400 and their Surety Bond in order to handle a larger sum of cash. Four staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Noel Camatog (7032675730) is up to date and expires 02/06/2025.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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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: CICADA-MILL VALLEY
FACILITY NUMBER: 216801993
VISIT DATE: 06/21/2024
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Continued from LIC809

No deficiencies cited during inspection.


Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 07/21/2024:


Updated LIC 400 Affidavit Regarding Client Cash Resources

Updated Surety Bond
LIC 500 Personnel Report

LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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