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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803824
Report Date: 06/21/2022
Date Signed: 06/22/2022 05:41:13 PM


Document Has Been Signed on 06/22/2022 05:41 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:CHENIN BLANC ASSISTED LIVINGFACILITY NUMBER:
486803824
ADMINISTRATOR:JONES, NIKIYAHFACILITY TYPE:
740
ADDRESS:5326 CHENIN BLANC PLACETELEPHONE:
(707) 208-6451
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:4CENSUS: 0DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Nikiyah JonesTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA), Araceli Canela arrived at Chenin Blanc Assisted Living for the purpose of conducting a Required-1 year inspection. LPA was greeted at the front door by Nikiyah Jones who granted access into the facility. Facility census is currently 0 and also employs no staff as of yet.

LPA toured the facility with the Administrator. The home was a comfortable temperature, was clean and in excellent condition. Smoke detectors and carbon monoxide detector were tested and operational. The fire extinguishers located in the kitchen and hallway were new and inspected during the Fire Safety Inspection. There are auditory alerts on exit doors and the fire extinguisher is charged and serviced. Water temperature will be within the required range of 105 to 120 degrees Fahrenheit. Bathrooms have required non-skid surfaces and grab bars. Cleaning products are stored in the locked garage. Knives are stored in a locked box in the kitchen. There is adequate space and furniture on the patio for outdoor activities. There was a 7 day supply of non-perishable foods and emergency food. There is a locked cabinet that will store residents' medications and a cabinet that will store resident and staff files.
LPA requested the following updated forms:
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property and liability insurance.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted with Administrator, Nikiyah Jones.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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