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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803302
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:54:58 PM

Document Has Been Signed on 11/15/2023 02:54 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:WILLIAMS BOARD & CARE HOMEFACILITY NUMBER:
486803302
ADMINISTRATOR:WILLIAMS, KATRINAFACILITY TYPE:
735
ADDRESS:430 FORDHAM DRIVETELEPHONE:
(707) 652-2445
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee, Katrina WilliamsTIME COMPLETED:
03:00 PM
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An Informal Meeting with Licensing Program Manager (LPM), Kimberley Mota, Licensing Program Analysts (LPAs), Farhaan Sarangi, Carol Fowler and Licensee/Administrator, Katrina Williams was held for the purpose of discussing Care and Supervision to clients in care and Medication Management.

Licensee explained that during the Required 1 year inspection, the caregiver went to retrieve her vehicle from the mechanic shop and the clients were left unsupervised. Licensing staff explained the importance of providing Care and Supervision to clients in care. During the Required 1 year inspection dated for September 14, 2023, the caregiver accidentally left the medication on the kitchen counter and not locked up. Licensee indicated that this is not the standard operating procedure. Licensee trained staff members regarding ensuring that medications are locked up and inaccessible to clients.

Licensing staff requested the following documents:

-LIC 500

Technical Service Program (TSP) was provided to the Licensee. No deficiencies were cited during today's Informal Office Meeting. Exit interview was conducted, and a copy of this report was signed and given to the Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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