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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803446
Report Date: 10/25/2024
Date Signed: 10/25/2024 08:13:12 PM

Document Has Been Signed on 10/25/2024 08:13 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/
DIRECTOR:		CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:259 CALAVERAS STREETTELEPHONE:
(707) 644-0826
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 0DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:21 PM
MET WITH:Reggie Smith, TIME VISIT/
INSPECTION COMPLETED:
03:52 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived announced to conduct this Required - 1 Year inspection. LPA was met by Reggie Smith, Property Manager, who arrived to conduct tour. Administrator Cheryl Davidson (CD) was notified of the inspection. There are currently no clients 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. Staff records will need to be updated, and include recent training 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. The fire extinguisher was last charged and serviced on 11/1/2023.

Administrator Certificate 6039075735 for Cheryl Davidson, expired on 5/15/2024 and submitted paperwork for renewal. Disaster drill will be conducted and documented every six months when clients are received.

Facility to notify Community Care Licensing/LPA once they get their first client.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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