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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801218
Report Date: 02/12/2024
Date Signed: 02/12/2024 03:36:17 PM


Document Has Been Signed on 02/12/2024 03:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:DOVER VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801218
ADMINISTRATOR:CECILIA JUANILLOFACILITY TYPE:
740
ADDRESS:752 ROSEMARY COURTTELEPHONE:
(707) 427-1105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 4DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Caregivers and AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct an annual inspection utilizing the full CARE inspection tool. LPA met with caregivers Emily Rapadas and Edgar Rapadas who contacted Administrator, Edward Gadia, who arrived to the facility shortly afterwards. LPA explained the purpose of the visit.

LPA and Administrator discussed changing Administrator on file. LPA requested a copy of Administrator Certificate to confirmed certification and will notify facility's assigned LPA of the following change.

During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six resident bedrooms, two bathrooms, laundry room, staff room, office, kitchen, backyard and the common areas. LPA observed knives, toxins, and medications to be locked and inaccessible to residents in care. LPA observed the exterior of the facility to be free from tripping hazards. LPA observed smoke alarms and carbon monoxides to be present and in operating condition. LPA observed facility to have ample supple of linens, and Personal Protective Equipment. LPA observed facility to have 2+ days of perishable and 7+ days of nonperishable foods. In areas toured, no immediate health safety and personal rights violation was observed.

LPA conducted a personnel and resident file review. LPA observed facility to have the required documents present on file. CARE inspection tool completed and facility is found to be in compliance. No deficiencies cited.

At this time, LPA request a copy of LIC 500, Administrator Certificate and liability insurance to be emailed to LPA Yang by Friday February 16, 2024.

Exit interview conducted and a copy of the report will be emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (279) 300-5157
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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