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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801931
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:21:41 PM

Document Has Been Signed on 11/14/2024 04:21 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:DUNGARVIN CALIFORNIA LLCFACILITY NUMBER:
486801931
ADMINISTRATOR/
DIRECTOR:		NOWLIN, JERAMIEFACILITY TYPE:
775
ADDRESS:310 E MONTE VISTA AVE STE ATELEPHONE:
(707) 449-3722
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 45CENSUS: 31DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Jeramie Nowlin, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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At approximately 12:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Required - 1 Year inspection and met with Jeramie Nowlin, Program Director (PD). LPA was informed that facility provides completely in-person services, Monday through Friday from 8:30 AM - 2:30 PM. The facility provides limited transportation services for clients. Facility is vendorized with North Bay Regional Center (NBRC) and each client has a services coordinator.

At approximately 1:30 PM, LPA conducted a walk-through of the facility and observed the following: there were 13 staff working and LPA was informed that facility maintains a 1:3 ratio of staff to clients. Clients were present and engaged in activities (arts and crafts, movies, working on computers, crossword puzzles, conversations, etc.) of their choosing during today's inspection. LPA observed a monthly calendar of outings, events, and activities planned. PD states that the clients help create the calendar each month by choosing what they would like to participate in. This includes choosing outings, lunch locations, cooking classes, music lessons, money management activities, shopping, movies, walks, media center activities, other social interactions and more.

LPA observed all exits unobstructed, chemicals stored in locked MSDS closet, and soap & paper towels were available in 4 of 4 facility bathrooms. PD advised to ensure all and water temperatures test within the allowable range of 105-120 degrees Fahrenheit per Title XXII regulations. LPA observed multiple first aid kits, PPE, emergency supplies, water, and an emergency food supply. Fire extinguishers were observed charged and were last serviced 11/2024. Smoke and carbon monoxide detectors were tested and operational.

At approximately 2:00 PM, LPA reviewed 5 staff and 6 client records. 5 of 5 staff have current training hours and certifications in First Aid & CPR. 5 of 5 staff have all the required documentation per regulation. 6 of 6 client records have all the required documentation per regulation.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: DUNGARVIN CALIFORNIA LLC
FACILITY NUMBER: 486801931
VISIT DATE: 11/14/2024
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Continued from 809...

The facility centrally stores and locks any PRN or scheduled medications clients may have per regulation. Facility does not handle client cash resources.

LPA requested the following updated forms to be submitted to Community Care Licensing (CCL) by 12/15/2024:
- LIC 500 Personnel Report
- LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for clients)
- LIC 9020 Register of Facility clients

No deficiencies cited during this inspection

Exit interview conducted with Program Director, whose signature on this document confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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