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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804095
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:25:54 PM

Document Has Been Signed on 11/01/2022 03:25 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:PROGRESS FOUNDATION - GRAND AVENUEFACILITY NUMBER:
216804095
ADMINISTRATOR:HERNANDEZ, ELIZABETHFACILITY TYPE:
772
ADDRESS:920 GRAND AVENUETELEPHONE:
(707) 257-9704
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 16CENSUS: 0DATE:
11/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator/Applicant, Elizabeth Hernandez, Program Director, AudreyTIME COMPLETED:
03:35 PM
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At approximately 10:15AM, Licensing Program Analyst (LPA) Felias arrived announced to complete a Pre-Licensing Inspection Visit and met with Administrator/Applicant, Elizabeth Hernandez, and Program Director, Audrey Land. Facility has submitted an Initial Application to have a Transitional Social Rehabilitation Facility with a total capacity of 16 Ambulatory clients. Facility has submitted documentation of their approved Fire Clearance.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA observed COVID-19 signs posted at the entry way and throughout the facility. Facility had sufficient amount of PPE available. All staff present were observed to be wearing a mask. LPA also observed that there is a construction fence surrounding the building premises and construction workers on site. Construction was observed to go up to the front entry way of the facility. Per conversation with Administrator and Program Director, construction is related to being compliant with The Americans with Disabilities Act (ADA) and local ordinance. Premises is in the process of constructing a ramp leading up to the front entrance of the facility and should be finished within a couple days.

LPA conducted a walk-through of the facility and observed the following: Facility is a single story residence, with 8 bedrooms, 4 full bathrooms and 1 half bathroom. 1 of the 4 full bathrooms and the 1 half-bathroom is ADA accessible. There is also a kitchen area, dining room, laundry room, and three staff offices. Facility has zero clients in care at this time. At full capacity, facility will have 2 clients sharing each bedroom.

Facility was observed to have a sufficient amount of perishable and nonperishable foods per regulation. Facility has an adequate supply of kitchen tools. LPA, Administrator, and Program Director discussed having sharps such as knives be placed in an area that is inaccessible to Clients unless they are in use and are supervised.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: PROGRESS FOUNDATION - GRAND AVENUE
FACILITY NUMBER: 216804095
VISIT DATE: 11/01/2022
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Continued from LIC-809

Of the 8 sinks to be used by clients, 7 were found to be within regulation with temperatures between the range of 105 degrees F to 120 degrees F. However, the facility's half bathroom sink was found to be out of acceptable temperature range at 88.7 degrees F.

Medications were observed to be locked and inaccessible to clients in care. There one laundry area available for Client Use. Toxins and Detergents were observed to be locked and inaccessible to clients in care. Per conversation with Program Director, clients will have a scheduled laundry day and will ask staff for detergent.

LPA observed Client rooms to be furnished per regulation. Client bathrooms were supplied with paper towels, liquid hand soap, and hand-washing signs. Facility was observed to have an adequate supply of the following products available for clients: extra linens, grooming, hygiene, and paper products.

Facility has an Emergency Disaster Plan in place. Fire extinguishers were purchased April 2022. Combination Smoke and Carbon Monoxide Detectors were tested and operational. Facility has a central fire alarm system that is directly connected to the Fire Department. Facility to conduct Fire Drills once every month.

Administrator had First Aid and CPR certificates available for LPA to review. Per conversation with Administrator, staff files are located electronically at their headquarters in Napa and San Francisco. LPA found all staff had current First Aid and/or CPR certificates. LPA, Administrator, and Program Director discussed ensuring that all staff are background cleared and associated to the facility.

LPA reviewed and discussed items in the Component III Orientation with Administrator and Program Director during visit.

LPA requesting that the following is submitted to CCL:
  • Proof of Completed Construction prior to admitting their first client to the facility
  • Proof of Water Temperature for half bathroom sink to be within the range of 105-120 degrees F.

Continued on LIC-809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PROGRESS FOUNDATION - GRAND AVENUE
FACILITY NUMBER: 216804095
VISIT DATE: 11/01/2022
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Continued from LIC-809C

Pre-Licensing completed. Component III Orientation conducted and completed. Facility is ready to be Licensed as a Transitional Social Rehabilitation Facility.

LPA will submit Pre-Licensing application report to Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of application status.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3