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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804278
Report Date: 01/21/2025
Date Signed: 01/21/2025 12:53:44 PM

Document Has Been Signed on 01/21/2025 12:53 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:ROSEBAY BEHAVIORAL HEALTHFACILITY NUMBER:
216804278
ADMINISTRATOR/
DIRECTOR:		LITCHFIELD, CHARLESFACILITY TYPE:
772
ADDRESS:200 VALLEY VIEW AVENUETELEPHONE:
(562) 916-6488
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 0DATE:
01/21/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Applicants, Charlie Litchfield and Rainey TemkinTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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At approximately 9:35AM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived announced to conduct a Pre-Licensing Inspection and met with Applicants, Charlie Litchfield and Rainey Temkin. Upon arrival, LPAs were informed that there were currently no clients in care. Facility received an approved fire clearance dated 11/12/2024 that allows for a total capacity of 6 ambulatory clients. Facility plans to provide services for adults with mental health diagnoses.

LPAs conducted a walk-though of facility with Applicants and observed the following: Facility is a one story residence with 3 client bedrooms, 3 bathrooms, 1 office space, a swimming pool, and common areas. Facility has a detached garage that is intended for storage. Per Applicant, facility's swimming pool has a protective cover sheet that requires a key to operate and will have at least one supervising staff member when clients utilize the pool. Facility has a gas fireplace located in their living room. Per applicants, the fireplace is only intended for decor purposes and requires a key to be turned on. At this time, the key is not on-site and is inaccessible to clients. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored in a locked closet in living room and inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All client rooms were furnished with a bed, lamp, dresser, and chair. Facility has sufficient items for cooking and eating. Applicants do not plan on managing client money. Files for staff and clients, and client medications will be located in the locked office. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers are newly purchased and were observed to be fully charged. Facility's combination smoke and carbon monoxide detectors were tested and operational. Facility's First Aid Kit were sufficient.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ROSEBAY BEHAVIORAL HEALTH
FACILITY NUMBER: 216804278
VISIT DATE: 01/21/2025
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Continued from LIC809

LPAs and Applicants discussed the following items:
  • Guardian Background Clearances and Associations
  • Conducting Proper Assessments
  • Electronic Files for Facility Staff and Clients
  • Keeping documentation logs
  • Component III was reviewed with Applicants.

LPAs provided Applicants with the following licensing forms:
  • LIC622 (central stored medication and destruction record)
  • LIC625 (needs and services plan)
  • LIC624 (unusual incident report)

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Social Rehabilitation Facility. LPAs 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 to Applicants. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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