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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803446
Report Date: 09/29/2023
Date Signed: 10/03/2023 12:15:00 PM

Document Has Been Signed on 10/03/2023 12:15 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: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:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Reggie Smith, Property Manager TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct this Required - 1 Year inspection. LPA was met by Stephanie Hodge, House Manager, who granted LPA access. Reggie Smith, Property Manager, arrived to conduct tour.. Administrator Cheryl Davidson (CD) was notified of the inspection. There are currently no residents at the facility. LPA toured the building and grounds. LPA observed all walkways and exits to be unobstructed.

The facility was a comfortable temperature and well lit. Water temperature in clients' bathrooms was within regulation between 105 to 120 degrees F. Toxins will be located and 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. 1 of the 4 bedrooms is ready for clients, however the other bedrooms are currently being used for storage. The facility will require some cleaning and organization prior to receiving clients/residents. Staff records will need to be updated, and include recent trainings and first aid/cpr certification.

Smoke detectors located throughout the facility were tested and functional. Carbon monoxide detector was also tested and found to be in working order. 2 fire extinguishers were last charged on 8/29/2022.

Administrator Certificate 6039075735 for Cheryl Davidson, expires on 5/15/2024. 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: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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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: 09/29/2023
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Prior to Licensee accepting resident to the faclitiy: required posters need to be posted, an Infection Control Plan submitted and Infection Control protocols prepared for implementation, soap and paper towels placed in restrooms, minor
repairs to doors and cabinets in kitchen, all toxins stored and locked to prevent resident access, fire extinguishers serviced and tagged, first aid/cpr certification for staff, active liability insurance policy in place.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 10/20/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Copy of Liability Insurance
Infection Control Plan
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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