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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480100774
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:23:10 PM

Document Has Been Signed on 10/28/2022 12:23 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:STRONG FAMILY HOMEFACILITY NUMBER:
480100774
ADMINISTRATOR:HATTIE STRONGFACILITY TYPE:
735
ADDRESS:141 HOLLYWOOD AVENUETELEPHONE:
(707) 644-1489
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lisa Strong-Dodson, House ManagerTIME COMPLETED:
12:30 PM
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On 10/28/2022, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee Hattie Strong and House Manager, Lisa Strong-Dodson. The facility currently provides care for three clients, two of which were present the time of visit and one of which was attending day program.

LPA arrived at the facility and had temperature checked. LPA continued with a tour of the facility with House Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Multiple fire extinguishers were located throughout the facility and found to be last charged on 7/29/2022 at the time of the visit. Smoke detectors and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. Facility has additional storage spaced located in the downstairs portion of the home containing cleaning supplies, additional non-perishable food and snacks for clients. LPA conducted a sample file review for 6 of 6 staff and found all to have current CPR and 1st Aid certification on file.

Toxins are stored in facility laundry room and maintenance storage closets all found to be secured. There was a supply of hygiene products and paper products available and kept in client individual bedrooms and storage areas. Facility provides all hygiene product to clients when requested. All client bedrooms have lighting & appropriate furnishings. Extra linens were stored in storage closets and available to clients. Medications and facility records are kept stored in the kitchen kept inaccessible to clients.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STRONG FAMILY HOME
FACILITY NUMBER: 480100774
VISIT DATE: 10/28/2022
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Infection Control:
Facility is to submit updated Infection Control Plan to CCLD for review by 11/11/2022. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature based on change of condition.
No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 11/11/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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