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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801782
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:36:54 PM

Document Has Been Signed on 11/20/2023 02:36 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:CO-OPFACILITY NUMBER:
486801782
ADMINISTRATOR:SIMMONS, SAMIKAFACILITY TYPE:
775
ADDRESS:320 CERNON STREETTELEPHONE:
(707) 449-9377
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 5DATE:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Floor Supervisor, Marcela EduardoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at CO-OP for the purpose of delivering complaint findings. LPA was greeted at the door by, Floor Supervisor, Marcela Eduardo and was granted access into the facility.


During the course of the investigation that was initiated on November 20, 2023, LPA learned that Community Care Licensing was not notified of the fall incident and the client becoming physically aggressive towards another client. LPA educated the staff members as it relates to Personal Rights of clients in care (See LIC 9102-Technical Violation).

No deficiencies were cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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