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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804130
Report Date: 09/04/2024
Date Signed: 09/04/2024 01:41:00 PM

Document Has Been Signed on 09/04/2024 01:41 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: 5DATE:
09/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Staff Member, Saran Von Doepp, and Program Director, Jade DolciniTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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09/04/2024 at approximately 10:50am, Licensing Program Analysts (LPA) Loera and Felias arrived unannounced to continue an Annual Required inspection that was initiated on 08/27/2024, and was greeted by staff. Program Director, Jade Dolcini arrived shortly after.

LPAs conducted spot medication count and found 2 of 4 to be properly recorded on the Centrally Stored Medication log. Based on records LPAs observed current medication was documented, however older medication was not documented. LPAs were informed by Program Director that facility has electronic files for clients and staff.

At approximately 11:30 am, LPAs conducted a review of five(5) client records. All records had the required documentation.

At approximately 12:30 pm, LPA conducted review of five (5) staff records/training. Upon a review of records, LPAs found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. However, Program Director was unable to access health screenings for review.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
  • Designation of Facility Responsibility (LIC308)
  • Updated Personnel Report (LIC500)

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation) 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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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