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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803356
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:24:50 AM

Document Has Been Signed on 10/27/2022 11:24 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:CORE ARF GADWALLFACILITY NUMBER:
286803356
ADMINISTRATOR:DADO,MYLENEFACILITY TYPE:
735
ADDRESS:3 GADWALL COURTTELEPHONE:
(707) 554-4802
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 2CENSUS: 2DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Mylene DadoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 10/27/2022 to conduct a required - 1 year inspection. LPA met with administrator, Mylene Dado. This inspection is focused on the infection control practices and procedures of this facility.

LPA toured building and grounds which were found to be clean and in good repair. Facility currently has two clients. Client bedrooms are located on the first floor. The amount of fresh and non-perishable food was within regulation. Fire extinguishers inspected were last charged on August 15, 2022. Toxins were locked and secured. Medications were centrally stored and locked. Carbon monoxide and smoke detectors were present and operational. Walkways were cleared and unobstructed. High touch surface areas are disinfected daily. LPA observed COVID postings at the front entrance. Visitation is preferred outside but is allowed indoors. Two clients attend a day program. Staff and clients are all fully vaccinated. Administrator has necessary Personal Protective Equipment to support a client in isolation. Clients can isolate in their own bedrooms if necessary. LPA and administrator discussed client/staff record keeping.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection:
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC402- Surety Bond
LIC 610 D Emergency Disaster Plan
Register of Clients
LIC 500 Personnel Report

Exit interview conducted with administrator and a copy of this report printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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