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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803489
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:19:29 PM

Document Has Been Signed on 01/29/2025 01:19 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:CAREMAX, INC. - LOGANBERRY HOMEFACILITY NUMBER:
216803489
ADMINISTRATOR/
DIRECTOR:
DIZON, AGNESFACILITY TYPE:
735
ADDRESS:599 LOGANBERRY DRIVETELEPHONE:
(415) 516-3162
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff Member, Huai Hen, Administrator, Agnes Dizon, and Designated Representative, Alan YangTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 9:00AM, Licensing Program Analysts (LPAs) Felias and Deniz arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Huai Hen, Administrator, Agnes Dizon and Designated Representative, Alan Yang, arrived to facility at approximately 9:30AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 2 ambulatory and 2 non-ambulatory clients with a total capacity for 4 Clients. Upon arrival, LPAs was informed that there were 4 clients in care, with all clients out of the community attending Day Program. LPAs were also informed that there was 1 staff member on-site.

LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Administrator. LPAs observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a two story building with 4 Client bedrooms, 3 staff rooms, 3 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. During walkthrough, LPAs observed a knife that was in an unlocked drawer (technical advisory issued, LIC9102, regulation 80087(g)). LPAs observed Administrator immediately place knife in an inaccessible cabinet. LPAs also observed 3 separate holes throughout the facility. 1 hole was located in the dining room and the other two holes were located in 2 client rooms. LPAs observed that all 3 holes were approximately 5 inches long. Per conversation with Administrator, the two clients have property destruction behaviors (technical advisory issued, LIC9102, regulation 80087(a)). During visit, facility staff fixed and patched all 3 holes.

LPAs reviewed staff and client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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: CAREMAX, INC. - LOGANBERRY HOME
FACILITY NUMBER: 216803489
VISIT DATE: 01/29/2025
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Continued from LIC809

Administrator's Certificate for Agnes Dizon (7008200735) was current with an expiration date of 06/24/2025.Fire extinguishers were last inspected October 2024. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire/disaster drill was conducted in January 2025.

LPAs requested the following documents to update facility file:

  • Administrative Organization (LIC309)
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Updated Surety Bond (LIC402)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610D)
  • Updated Personnel Report (LIC500)
  • Updated Liability Insurance
  • Updated Lease
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 2/29/2025.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Advisory) and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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