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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804135
Report Date: 07/18/2023
Date Signed: 07/18/2023 10:55:47 AM

Document Has Been Signed on 07/18/2023 10:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JOSHUA'S HAVENFACILITY NUMBER:
286804135
ADMINISTRATOR:TAMBOT-SUNGA, DEYRAFACILITY TYPE:
735
ADDRESS:236 NEWBURY WAYTELEPHONE:
(650) 892-4572
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 4CENSUS: 1DATE:
07/18/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff, Kamille NastorTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Bertozzi arrived unannounced to conduct a Post Licensing Inspection and was greeted by Direct Care Staff, Kamille Nastor. Licensee, Rowell Ferrer was available by phone and gave permission for staff to sign report.

LPA initiated a tour of the facility at 9:45am and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. There is currently one client in care and they were engaging in their day program via video conferencing during this visit. Water temperature in client's bathroom measured at 107 degrees F which is within allowable range of 105 to 120 degrees F. Cabinet containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

LPA observed two rooms in the garage that are not on the facility sketch provided during the application process. Per conversation with Licensee, the rooms are occupied by live-in staff. LPA has requested an updated sketch so that a fire clearance can be requested.

Fire extinguishers were charged and are not yet due for servicing. Smoke and Carbon Monoxide detectors were not tested due to client's sensitivity to loud noises.

Two staff files and one client file were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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