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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800557
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:53:55 PM

Document Has Been Signed on 03/06/2025 01:53 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:I.M.P.A.C.TFACILITY NUMBER:
486800557
ADMINISTRATOR/
DIRECTOR:		JOETTA GRIFFINFACILITY TYPE:
775
ADDRESS:2573 CLAY BANK ROAD, SUITE 12TELEPHONE:
(707) 862-2105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 90CENSUS: 40DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Gabby Echevarria - administratorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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At approximately 9:40AM Licensing Program Analyst (LPA) Stevenson conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Director, Gabby Echevarria. The facility currently provides care for 40 clients, 37 of which were at the facility at the time of visit.

At approximately 10:15AM LPA continued with a tour of the facility with Director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were found to be last charged March 12, 2024 and are expected to be re-inspected this month. Carbon monoxide detector located in main common area was tested and found to be in working order.
LPA was informed that an outside agency will conduct an annual fire inspection later in this month on March 12th, 2025. Facets available to clients in care were found to be within 105 to 120F. Staff sink behind locked door was found to be 98F degrees and technical advisory given to ensure staff water heater is inspected and ensured to be working properly.

Clients were observed to be engaged in various group activities including, large group discussion, arts & crafts, puzzles, karaoke, beading, painting, bingo with prizes, computers, piano, air hockey, big screen TVs,one-on-one classes and other options to choose during program hours. During the visit, several clients were on public outings with staff. Staffing was found to be sufficient. Clients observed to have positive relationship with staff continuously engaging and participating with clients. LPA was informed that clients currently provide their own meals with snacks provided throughout the day. Facility primarily holds outdoor activities during outings and also has a large outdoor parking lot area located in the rear of the building for client use. Toxins, cleaning supplies and other potentially dangerous items are stored in a designated cleaning supply closet inaccessible to clients. All other storage closets and containers holding items that could potentially be a danger to clients if accessible were all found to be locked and secured.
Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: I.M.P.A.C.T
FACILITY NUMBER: 486800557
VISIT DATE: 03/06/2025
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Continued from LIC809
At approximately 11:45 LPA conducted a file review of staff records and observed two (2) of five (5) to have expired 1st aid (see S1 and S2 on LIC811) LPA conducted sample file review of client records and observed one (1) of five (5) to be missing MD assessment (LIC602) with TB clearance (see C1 on LIC811)

LPA provided recommendation on file organization for staff and client records. Technical Advisory and Technical Violations Issued. In addition, facility will need to update Emergency Disaster Plan.

Spoke via phone with Licensee Joetta Griffin who reports they will supply a new Affidavit to no longer handle cash resources for clients; Licensee also provided visual proof of current licence fees being paid.

LPA requested the following documents be sent to CCL by COB 4/06/2025:
LIC 400 Affidavit Regarding Client/Resident Cash Resources (Licensee indicated by phone they no longer handle client cash)
LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of current lease
Fire Inspection Report

No deficiencies cited during today's visit
.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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