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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111090
Report Date: 05/07/2024
Date Signed: 05/09/2024 11:32:04 AM

Document Has Been Signed on 05/09/2024 11:32 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:GILCREST GROUP HOME, THEFACILITY NUMBER:
480111090
ADMINISTRATOR/
DIRECTOR:
CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:447 GILCRESTTELEPHONE:
(707) 563-5543
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 9CENSUS: 8DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:32 PM
MET WITH:Ruby Daniels, care staff TIME VISIT/
INSPECTION COMPLETED:
04:48 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with staff, Ruby Daniels Administrator, Cheryl Davidson was available by phone. There is currently 8 clients in care & this facility is licensed for a capacity of 9 Ambulatory clients.

LPA toured facility and grounds and observed the home be at a comfortable temperature with all exits free from obstruction. CLients rooms require a reading lamp. Water temperature in bathrooms used by clients is within the required range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinet in staff room containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications are centrally stored and locked. Emergency food and water supplies are stored in office. Facility has smoke detectors located throughout the facility as well as a Carbon Monoxide detector that were operational during inspection. Fire Extinguishers were found to be last charged and serviced on January 29, 2024.

Client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Cheryl Davidson #6039075735 expires 5/15/2024.

No citations issued.
Licensee/Administrator to submit copies of the following documents by 6/1/2024: LIC9020 Register of Clients; LIC 500 Personnel Summary; LIC 308 Designation of Responsibility; LIC 610 Emergency Disaster Plan (If changes) Infection Control Plan (If changes)
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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