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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803644
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:50:34 PM

Document Has Been Signed on 09/17/2024 02:50 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:LYNWOOD HOMEFACILITY NUMBER:
216803644
ADMINISTRATOR/
DIRECTOR:		LIU, FANGFACILITY TYPE:
735
ADDRESS:1212 LYNWOOD DRIVETELEPHONE:
(415) 516-3162
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Annie Liu (Adminstrator)TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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09/17/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Annie Liu (Administrator). Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently four(4) clients in care.

At approximately 12:50pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.



Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 109 degrees within the range of 105 to 120 degrees F. Fire extinguishers were last inspected May, 2024. Smoke/Carbon Monoxide detectors are located throughout the facility are hardwired and were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located under the kitchen sink and found to be secured. Extra supplies such as cleaning products were found to be locked and secured in the garage. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Cash resources and documentation were reviewed. Facilities last fire drill was conducted 08/2024.

At approximately 1:20pm, LPA conducted a review of four clients records. All records had the required documentation.

continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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: LYNWOOD HOME
FACILITY NUMBER: 216803644
VISIT DATE: 09/17/2024
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At approximately 2:00pm, LPA conducted review of four staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond
LIC400- Cash Affidavit for Clients

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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