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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803446
Report Date: 10/14/2021
Date Signed: 10/15/2021 10:50:40 AM

Document Has Been Signed on 10/15/2021 10:50 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:DOWNIE ST. HOMEFACILITY NUMBER:
486803446
ADMINISTRATOR:CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:259 CALAVERAS STREETTELEPHONE:
(707) 644-0826
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jacqueline Brown-Turner, Office ManagerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Tobola met with Office Manager, Jacqueline Brown-Turner (JBT) to conduct this Required - 1 Year inspection. Administrator Cheryl Davidson (CD) was notified of the inspection. LPA toured the building and grounds which was found clean and in good repair. LPA observed all walkways and exits to be unobstructed.

The facility was a comfortable temperature and well lit. Water temperature in resident's bathrooms is within regulation between 105 to 120 degrees F. Toxins are located in the locked in laundry room. Medications will be centrally stored and locked once clients are acquired. Cash resources, medications, toiletries and client records are not available as the facility has not had any clients in care for several years.

Administrator agrees that that the fire extinguisher located in the hallway will need to be serviced as soon as they have clients in care. JBT stated that a new fire extinguisher has been purchased and will replace current extinguisher. Smoke detectors located throughout the facility were tested and functional. Carbon monoxide detector was functional.

Administrator Certificate for Cheryl Davidson, expires on 5/15/2022. Staff have required First Aid certificates. Disaster drill will be conducted and documented every six months when clients are received.

No deficiencies cited during the visit.

Copy of electronic report was provided to Office Manager and Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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