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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804130
Report Date: 07/25/2023
Date Signed: 07/25/2023 01:07:35 PM

Document Has Been Signed on 07/25/2023 01:07 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:AVERY LANEFACILITY NUMBER:
216804130
ADMINISTRATOR:HILDEBRAND, CAMILLEFACILITY TYPE:
772
ADDRESS:200 ATHERTON AVETELEPHONE:
(415) 686-6127
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 0DATE:
07/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Camille Hildebrand, Director & Anna-Lena Karlsson, Compliance DirectorTIME COMPLETED:
01:15 PM
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At approximately 8:30AM, Licensing Program Analyst (LPA) Hansen arrived to conduct a Pre-Licensing visit of this Social Rehabilitation Facility and met with Director, Camille Hildebrand & Anna-Lena Karlsson, Compliance Director. Fire clearance has been approved for 6 ambulatory clients by the Novato Fire Protection District. The facility currently has no clients in care.

LPA conducted a walk-through of the facility and observed the following: Facility is a two-story residence, with 3 bedrooms, 1 bedroom on the main floor and 2 on the second story. There are 3 full bathrooms and 1 half bathroom. There is also a kitchen area, dining room, laundry room, living room, group room, recreation room, and three staff offices. At full capacity, facility will have 2 clients sharing each bedroom.

LPA also observed that the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip mats were present. Bathrooms were supplied with paper towels, liquid hand soap, and hand-washing signs. Hot water temperature checked between 105 degrees F and 120 degrees F in all client’s bathroom faucets as required by Title 22 Regulations. Toxins were secure and inaccessible to clients. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use.



Facility has an adequate supply of kitchen tools. Per conversation with Director, sharps such as knives will be stored and locked in the facility's pantry room in locked sharps box. Facility will have culinary team that will cook all of the clients food.

LPA observed medication cabinets with lock in the facility's medical office space that will also be locked. Per conversation with Director, client medications will be located here and clients will wait in a designated area when receiving their medication.
Continued from LIC809
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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 2
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: AVERY LANE
FACILITY NUMBER: 216804130
VISIT DATE: 07/25/2023
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There is one laundry area in the facility. Toxins and Detergents will be located in a locked cabinet in the laundry room and in a locked closet adjacent to the laundry room, locked and inaccessible to clients in care. Per conversation with Director, if clients want to do their laundry, they will ask a staff member for the detergent. The staff member will obtain the detergent from the locked closet and give it to the client.

Per conversation with, the facility's Director main exit doors and all windows are equipped with sensors. Clients will always be in the line of sight of Facility staff when outside to ensure their safety.

Facility has an Emergency Disaster Plan in place. First aid kit was observed. Emergency supplies located in the operations office and some in the medical office. Fire extinguishers were last serviced January 4, 2023. Combination Smoke and Carbon Monoxide Detectors were tested and operational. There is a sprinkler system throughout the house that is annually checked by Fire King and a private alarm system that is connected to local law enforcement.

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

No Advisories provided during visit.

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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