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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803761
Report Date: 08/09/2022
Date Signed: 08/09/2022 12:08:46 PM

Document Has Been Signed on 08/09/2022 12:08 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:COMMUNITY CONNECTION, THEFACILITY NUMBER:
236803761
ADMINISTRATOR:PEREZ-MORAN, RODRIGOFACILITY TYPE:
775
ADDRESS:521 CHESTNUT STTELEPHONE:
(707) 964-1489
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 30CENSUS: 2DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Xaviera HallTIME COMPLETED:
12:15 PM
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At approximately 10:30AM, 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. LPA met with Administrator Xaviera Hall and toured the facility. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has submitted and received approval for an Infection Control 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 supply closet. There were hand washing stations and hand sanitizer located throughout the building.

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: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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