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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800164
Report Date: 06/08/2023
Date Signed: 06/09/2023 12:36:45 PM

Document Has Been Signed on 06/09/2023 12:36 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:CLARK-RO RESIDENTIAL CARE IIFACILITY NUMBER:
486800164
ADMINISTRATOR:SKILLMAN, ROSIE L.FACILITY TYPE:
735
ADDRESS:1234 LOUISIANA STREETTELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 0DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Judy JohnsonTIME COMPLETED:
04:44 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced Annual Required – 1 yr. inspection for this facility and met with Lead Staff, Judy Johnson (JJ). LPA called and spoke with JJ, who arrived a few minutes later. The facility currently has 0 clients in care and it is licensed to care for up to 6 Ambulatory clients. No approval for non-ambulatory or bedridden clients. This facility is a 2 story home with 5 bedrooms that will be used by clients and 2 bedroom that will be used by staff/0ffice. The facility is in process of admitting a potential client. The Licensee will keep LPA updated on facility operations.
LPA toured the facility with staff and 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. Fire Extinguisher was found to be charged and serviced. There will be sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations as soon as the first client moves in. Toxins are stored and will be locked in cabinet in the laundry room. LPA tested facility smoke alarms and carbon monoxide and found them to be in working condition. Medications will be kept in a secured cabinet. The facility will have a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Facility staff have proof of 1st Aid & CPR. Water temperature read 108 degrees F. and within the required 105-120 degrees F.

Licensee to submit updates of the following documents by 6/30/2023.
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond (If applicable)
· Infection Control Plan of Operation (If changes)
No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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