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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804130
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:16:42 PM

Document Has Been Signed on 08/27/2024 03:16 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:AVERY LANEFACILITY NUMBER:
216804130
ADMINISTRATOR/
DIRECTOR:		HILDEBRAND, CAMILLEFACILITY TYPE:
772
ADDRESS:200 ATHERTON AVETELEPHONE:
(415) 686-6127
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Staff Member, Pam Brown, and Program Director, Jade DolciniTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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08/27/2024, Licensing Program Analysts (LPA) Loera and Felias conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPAs met with Staff Member, Pam Brown. Program Director, Jade Dolcini arrived during visit at approximately 2:00pm. Upon arrival facility had four staff members and four clients on sight. Facility has infection control plan as required. Facility is approved for six(6) ambulatory.

At approximately 2:15pm, LPAs and Program Director toured the building and grounds. The facility was found to be at a comfortable temperature. LPAs 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 being labeled and dated.

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 within the range of 105 to 120 degrees F. Fire extinguishers were last inspected January, 2024. Facilities last fire drill/emergency drill was conducted August 2024.

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

No Deficiencies Cited during visit.



Exit interview conducted. Copy of report discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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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