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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803446
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:07:32 AM

Document Has Been Signed on 09/20/2022 11:07 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Stephanie Hodge, OccupantTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tobola met House Manager, Stephanie Hodge 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 client'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 in cabinets located in hallway 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.

Smoke detectors located throughout the facility were tested and functional. Carbon monoxide detector was also tested and found to be in working order. Fire extinguisher is located in the kitchen and last charged on 8/29/2022.

Administrator Certificate 6039075735 for Cheryl Davidson, expires on 5/15/2024. Staff have required First Aid certificates on file. Disaster drill will be conducted and documented every six months when clients are received.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DOWNIE ST. HOME
FACILITY NUMBER: 486803446
VISIT DATE: 09/20/2022
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Infection Control:
Facility to submit Infection Control Plan which will be reviewed. All staff have been vaccinated with no reported or observed symptoms. Posters are readily available to be placed at the front door, hallways and restrooms promoting COVID mitigation. Facility has COVID protocols prepared for implementation once Licensee decides to admit clients into the facility.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 9/27/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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