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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801015
Report Date: 06/07/2022
Date Signed: 06/07/2022 11:58:06 AM

Document Has Been Signed on 06/07/2022 11:58 AM - 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:HARPE HOME, THEFACILITY NUMBER:
236801015
ADMINISTRATOR:HARPE, CYNTHIAFACILITY TYPE:
735
ADDRESS:800 TOKAY AVENUETELEPHONE:
(707) 489-3685
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 2CENSUS: 2DATE:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cynthia HarpeTIME COMPLETED:
12:15 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted to CCL on 05/18/2022. LPA met with Administrator Cynthia Harpe and reviewed records. The incident involved a Client, C1, going to a friends house, locking themselves in a room and threatening to do harm to self. C1 was texting threats of harm to self to the Administrator and local law enforcement were notified. Law enforcement was able to calm the situation and C1 returned to the facility. LPA received copies of care plan and physician report. C1 is able to be in the community by themselves.
A medication change was made by the physician to address these behaviors.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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