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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804095
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:39:35 PM

Document Has Been Signed on 11/21/2024 02:39 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:PROGRESS FOUNDATION - GRAND AVENUEFACILITY NUMBER:
216804095
ADMINISTRATOR/
DIRECTOR:		O'BRIEN, KELSEYFACILITY TYPE:
772
ADDRESS:920 GRAND AVENUETELEPHONE:
(707) 257-9704
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 16CENSUS: 14DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Assistant Program Director, Sean LunaTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Assistant Program Director, Sean Luna. Program Director, Kelsey O'Brien was available by telephone. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health. Facility has an approved fire clearance and capacity for 16 Ambulatory clients. Upon arrival, LPA was informed that there were 14 clients in care, and 3 staff members on-site.

At approximately 12:55PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1PM, LPA conducted a walk-though of the facility with Assistant Program Director. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with 8 bedrooms, 4 1/2 bathrooms, common areas and staff offices. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and dangerous items 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. Facility's fire extinguishers were last inspected October 2023 (deficiency cited, LIC809D, regulation 81020(a)(1)). Facility's smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


Exit interview conducted. Copy of report, LIC-809D (Deficiency Page),Plan of Corrections, and Appeal Rights discussed and provided to Assistant Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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Document Has Been Signed on 11/21/2024 02:39 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/21/2024 at 02:23 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: PROGRESS FOUNDATION - GRAND AVENUE
FACILITY NUMBER: 216804095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81020(a)
81020 Fire Clearance: (a) A social rehabilitation facility shall secure 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 observations made, Licensee did not comply with the section cited above. Licensee did not ensure that 3 of 3 fire extinguishers were serviced or inspected annually as required. Facility contacted vendor and scheduled inspection for fire extinguishers during visit. This poses an immediate health and safety risk to clients in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee contacted vendor company to have the fire extinguishers serviced during visit. Licensee to submit written plan on how facility will maintain and ensure compliance with servicing fire extinguishers annually by POC due date of 11/22/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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