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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804031
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:58:05 AM

Document Has Been Signed on 03/22/2024 10:58 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:PHOENIX HOUSEFACILITY NUMBER:
236804031
ADMINISTRATOR:ADDISON, DENISEFACILITY TYPE:
772
ADDRESS:641 S ORCHARD AVETELEPHONE:
(707) 467-2010
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 8CENSUS: 7DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sarah LivingstonTIME COMPLETED:
11:10 AM
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At approximately 8:15 AM , Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced to conduct an Annual Required inspection. LPA met with Program Director Sarah Livingston. At approximately 8:45 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins were stored properly. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Facility has a common computer with internet access for client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has Fire Sprinklers throughout. Carbon Monoxide detectors were present. Disaster Drills are conducted quarterly..
At approximately 9:15 AM, LPA reviewed 7 Client records. 1 of 7 records did not contain a medical assessment. All other required documents were present. Staff records contained all required documents. First aid certification was current in staff files reviewed.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Evidence of control of property
LIC500- Personnel Report
LIC308- Designation of Responsibility
Infection control plan

No deficiencies were found in the areas inspected, No citations issued during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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