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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803378
Report Date: 12/05/2024
Date Signed: 12/05/2024 05:03:23 PM

Document Has Been Signed on 12/05/2024 05:03 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:CARE GREATFACILITY NUMBER:
486803378
ADMINISTRATOR/
DIRECTOR:		ZHANG, GUOLIAN (MARK)FACILITY TYPE:
735
ADDRESS:3265 VISTA DEL LAGO WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
12/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Silva Rosario, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow-up visit regarding an incident report received by CCL on 10/11/2024 from Client 1's (C1's) Day Program and was greeted by Silva Rosario, House Manager. The report states that C1 was observed with bruising to their groin area during body checks by Day Program staff.

LPA interviewed House Manager, obtained documents and made observations. Based on the information gathered, C1 has a known, documented condition which causes them to bruise easily and has been observed on multiple occasions with bruising which has also been documented. House Manager states that North Bay Regional Center (NBRC) and C1's care team are aware of the situation and there is not anything they can do to prevent bruising in C1's situation. House Manager states that the Day Program is aware of this condition too.

House Manager states that an incident report was submitted and provided LPA a copy of the report. LPA informed House Manager that it had only been sent to NBRC and not to CCL. LPA advised House Manager to submit all future incident reports to CCL separately and within 7 days of the incident. LPA provided House Manager the CCL email. House Manager understands and agrees.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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