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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803659
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:41:22 AM

Document Has Been Signed on 03/10/2022 11:41 AM - 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:AUTISTRY STUDIOSFACILITY NUMBER:
216803659
ADMINISTRATOR:LAWSON, JANET KFACILITY TYPE:
775
ADDRESS:448 DU BOIS STTELEPHONE:
(415) 454-1037
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 30CENSUS: 21DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Chief Operating Officer, Daniel Swearingen
Program Director, Janet Lawson
Officer Manager, Rhoda Robertson		TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Autistry Studios for the purpose of performing a Required-1 year inspection. LPA was met at the door by Chief Operating Officer (COO), Daniel Swearingen and was granted access into the facility. Program Director, Janet Lawson and Officer Manager, Rhoda Robertson arrived 20 minutes later.

LPA toured the facility with Chief Operating Officer, Daniel Swearingen. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured building and grounds, day activity rooms, kitchen, and bathrooms. Smoke detectors and sprinklers system are hard wired – audible and visual alarms. There are 5 hardwired smoke/CO detectors. COO states that hard wired smoke detectors and sprinklers system will have an inspection in June 2022. Fire extinguishers are fully charged with last inspection on September 2021. First aid kit was appropriate during inspection. Facility does not transport clients at this time. Toxins, chemicals and hazardous items were safely stored in a locked cabinet under the kitchen sink. Bathrooms were all equipped with soap dispensers and individual paper towels. There is a sufficient supply of sanitary products on hand. Hot water temperature measured between 115.3 degrees F and 108.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms. Clients provide their own snacks and lunches but program will supply food for special occasions. There is one large refrigerator available for client food. Facility doesn’t administer medications. LPA requested the following Licensing Documents:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Control of Property/Grant Deed of Trust/Lease of Property
(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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: AUTISTRY STUDIOS
FACILITY NUMBER: 216803659
VISIT DATE: 03/10/2022
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In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills will resume in the coming weeks. Facility has PPE supply stored in the Administrator office at the facility. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

No deficiencies observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Program Director.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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