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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803493
Report Date: 05/22/2023
Date Signed: 05/22/2023 02:21:55 PM

Document Has Been Signed on 05/22/2023 02:21 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:CH&S LIFE COLLEGEFACILITY NUMBER:
216803493
ADMINISTRATOR:ABATE, CHASFACILITY TYPE:
775
ADDRESS:837 SWEETSER STREETTELEPHONE:
(415) 897-8676
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 18CENSUS: 10DATE:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Program Director, Jennifer HarterTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at CH&S Life College for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Program Director, Jennifer Harter, and was granted access into the facility.

LPA and Program Director toured the facility. Facility was found to be clean in good repair and at a comfortable temperature. The facility consists of a kitchen, 2 bathrooms, three activity rooms, outdoor patio, and a staff office. Hot water measured at 106 degrees which is within Title 22 regulations of 105 to 120 degrees F in 2 of 2 faucets used by clients. Participants typically bring their own lunches and snacks unless there is a party or special occasion. All exits were found to be unobstructed. Facility does not assist with Medication Dispensing. Fire extinguishers were observed with an inspection tag date of March 2022, but were outdated (See LIC 809D and Observation/Photo). Carbon Monoxide and Smoke Detectors were tested and found to be operational during the inspection. First Aid kit was inspected and found to be appropriate during the inspection. Infection Control Plan was reviewed with the Program Director. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Emergency Disaster Plan was reviewed with the Program Director. Emergency Disaster Drills are conducted every 6 months. During this required 1 year inspection, LPA reviewed 4 staff files. 1 out of 4 staff files did not have the 8 hours of required training (See LIC 9102-Technical Advisory) . 5 client files were reviewed and found that 1 out of 5 clients do not have an updated Individual Service Plan (ISP) (See LIC 9102-Technical Advisory). LPA interviewed staff and clients in care at the time of the inspection. LPA requested the following documents:

LIC 500-Personnel Report
LIC9020-Register of Clients/Residents
LIC 308-Designation of Responsibility (If applicable)

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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: CH&S LIFE COLLEGE
FACILITY NUMBER: 216803493
VISIT DATE: 05/22/2023
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Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted with the Program Director, and appeal rights were given along with this report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 02:21 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 05/22/2023 at 01:48 PM
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: CH&S LIFE COLLEGE
FACILITY NUMBER: 216803493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82020
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation review, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care. Facility fire extinguisher was last charge on March 2022. Facility didn't comply with State Fire Marshal requirements.
POC Due Date: 05/29/2023
Plan of Correction
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Facility to ensure that fire extinguishers are checked and charged annually. Facility agrees to have fire extinguisher charged and submit proof of service to Department by POC due date of 05/29/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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