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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803269
Report Date: 04/05/2024
Date Signed: 04/05/2024 12:35:31 PM

Document Has Been Signed on 04/05/2024 12:35 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:RIVERLAND PLACEFACILITY NUMBER:
216803269
ADMINISTRATOR/
DIRECTOR:		BENOIT, WILSONFACILITY TYPE:
735
ADDRESS:49 PICO VISTATELEPHONE:
(415) 756-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 4DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator, Wilson BenoitTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:10AM to conduct an Annual Required inspection and was greeted by staff. LPAs and staff discussed the purpose of the visit. Administrator, Wilson Benoit arrived shortly after.

LPAs and Administrator initiated a tour of the facility around 09:40 AM and made the following observations: Upon entering facility, temperature was read in the main room as 57 degrees F. Administrator immediately turned the heater on and a comfortable temperature was reached. Passageways were free from obstructions. Resident rooms were furnished per regulation. LPAs observed moldy jicama and a peeled orange on client dresser and night stand. Administrator immediately disposed of the fruit. Water temperature in sinks accessible to clients measured at 109 and 119 degrees F which are within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were unlocked and Administrator immediately locked them. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in outside refrigerator. Personal Protective Equipment is stored in a file cabinet.

Fire extinguishers were last serviced May 1, 2023. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 01/05/2024. Client cash resources were reviewed. LPAs observed that facility was $150 over the cash limit than allowed per facilities LIC 400 (Affidavit Regarding Client Cash Resources). LPAs are requesting an updated LIC 400 and Surety Bond.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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: RIVERLAND PLACE
FACILITY NUMBER: 216803269
VISIT DATE: 04/05/2024
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Continued from LIC809

Five staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Wilson Benoit (6006356735) is up to date and expires 01/31/2025.

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 05/05/2024:

LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
LIC 400 Affidavit Regarding Client Cash Resources
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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