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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803525
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:11:59 PM

Document Has Been Signed on 06/19/2024 12:11 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:DARWIN FACILITYFACILITY NUMBER:
486803525
ADMINISTRATOR/
DIRECTOR:
HALL, MYRTLEFACILITY TYPE:
735
ADDRESS:1612 TUCSON CIRCLETELEPHONE:
(707) 426-4981
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 2DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Joanna Hall, Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and met with Joanna Hall, Lead Caregiver (LC). At approximately 9:35AM, LPA and LC toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Two out two client rooms were inspected and found to be within regulation. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 114 and 116 degrees F at three if three faucets accessible to clients. Six out of seven smoke detectors were inspected and found to be in working order. One of seven smoke detectors and one out of one carbon monoxide detector was not found to be in working order. LC will replace batteries and provide proof of correction to LPA. One out of one fire extinguisher was fully charged and inspected on 01/05/2024. Disaster Drills are conducted quarterly with the last drill conducted 02/17/2024.

At approximately 10:20 AM, LPA reviewed two of two Client records which were all found to be well organized, thorough and contained the required documentation. At approximately 10:45 AM, LPA reviewed two out of two staff records which were all found to be well organized. One staff file is missing health screen and TB results. Per LC will provide to CCL. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. Administrator's Certificate for Myrtle Hall certificate #7006901735 is current and expires on 12/03/2024.

No citations issued during today’s visit


Continue on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DARWIN FACILITY
FACILITY NUMBER: 486803525
VISIT DATE: 06/19/2024
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Continued from 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC610D- Disaster Plan (updated non-local evacuation site)
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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