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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 09/21/2021
Date Signed: 09/21/2021 10:11:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CEDARS CARE HOME, THEFACILITY NUMBER:
286800667
ADMINISTRATOR:SHERWOOD, LAURAFACILITY TYPE:
740
ADDRESS:1520 CEDAR STREETTELEPHONE:
(707) 942-9200
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:12CENSUS: 10DATE:
09/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paulina LopezTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Angela Elliott arrived unannounced to conduct a case management related to incidents. LPA met with Viridiana (Viri) Agapoff, Manager.

The first incident occurred on 9/2/2021. R1 went out their side door and out into the street due to hearing noises outside. The alarm on the door was activated when they opened the door. S1 kept R1 in sight the entire time. S1 was able to re-direct R1 back into their room. Per Viri care plan was not updated as a result of this incident. R1 is monitored constantly and there have been no similar incidents.

The second incident occurred on 9/20/2021. R1 was discovered on the floor of their bedroom. R1 indicated that they were trying to get to their bed from their wheelchair but slipped. Fire Department assisted with getting R1 off the floor, no injuries sustained. Incident report reflects R1 said it was S2's fault that it happened. Per incident report S2 was in their office at the time. Per Viri care plan was not updated as a result of this incident, and resident is doing well.

No citations for deficiencies issued. LPA also dropped off PPE.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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