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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803677
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:07:49 PM

Document Has Been Signed on 09/07/2023 03:07 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:A RESIDENCEFACILITY NUMBER:
486803677
ADMINISTRATOR:ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:2264 CAMBRIDGE DRIVETELEPHONE:
(707) 631-3655
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Higinia Alvis, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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LPA Carol Fowler conducted an unannounced POC visit to make a follow up on a deficiency cited on 08/15/2023. LPA met and toured garage with Administrator Higinia Alvis.

The following CCL deficiency cited on 08/15/2023 and status of POC is as follows:
  • 85087(a)(3)(A) (3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. INCOMPLETE


Licensee has not corrected the POC by the due date. Civil Penalties issued.

Deficiency cited on LIC 809 D, dated 8/15/2023 is found to not be corrected. Civil penalties are being assessed today in the amount of $250.00 for failure to correct POC and will continue to run at $250.00 per day until corrected.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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Document Has Been Signed on 09/07/2023 03:07 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/07/2023 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: A RESIDENCE
FACILITY NUMBER: 486803677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
85087(a)(3)(A)

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(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways,..., garages, storage areas, and sheds, or similar detached buildings.
This requirement is not met as evidenced by:
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Administrator has printed and completed form LIC200 during this visit and has emailed a facility sketch to LPA on 8/18/2023 with 2 additional bedrooms that were created in the garage.
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Based on observation, the licensee did not comply with the section cited above by not correcting POC by the due date of 8/22/2023 and having a 2 bedrooms created in the garage area still occupied by staff, that has not been fire cleared or on the facility sketch, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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