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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236800266
Report Date: 06/21/2022
Date Signed: 06/21/2022 01:03:30 PM

Document Has Been Signed on 06/21/2022 01:03 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:RURAL ADULT PROGRAMFACILITY NUMBER:
236800266
ADMINISTRATOR:SEAN BASHAWFACILITY TYPE:
775
ADDRESS:209 W. MILL STREETTELEPHONE:
(707) 468-8824
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 30CENSUS: 9DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kerri RichardsonTIME COMPLETED:
01:15 PM
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At approximately 12:00 AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this licensed adult day program unannounced, to conduct an Annual Required infection control inspection. LPA arrived at the facility and had temperature checked and health questions asked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA met with Program Manager Kerri Richardson and toured the facility. Facility has submitted and received approval for a Covid Mitigation plan. Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for Clients, Staff and visitors before coming into the facility. Facility has PPE supplies stored in the office. There were hand washing stations and hand sanitizer located throughout the building. There are currently 9 clients attending the day program.

There were no deficiencies found in the areas inspected. No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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