<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803956
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:58:31 PM

Document Has Been Signed on 01/28/2025 01:58 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:CONNECTED LIVING VACAVILLEFACILITY NUMBER:
486803956
ADMINISTRATOR/
DIRECTOR:		KATRINKA TRAILFACILITY TYPE:
735
ADDRESS:82 MANZANITA DRIVETELEPHONE:
(925) 826-6830
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 5CENSUS: 4DATE:
01/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Cedric Tanner, Facility DirectorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a Case Management - Deficiencies Inspection. The purpose of this case management visit was to follow up on a self reported incident report that was submitted to Community Care Licensing (CCL) on 11/08/2024 regarding client C1 as well as to cite deficiencies for regulatory violations observed during today's inspection.

During visit LPA went over incident details, gathered records, took statement from Facility Director, and made observations. Per review of today's records and interviews, staff addressed the incident as needed, when it occurred. Further, LPAs were informed that the aggressor in the situation reported has been discharged from C1's Day Program and they no longer have interactions.

Additionally, during today's visit LPAs observed the following areas of noncompliance, (see LIC809D):
Missing Pre-placement Appraisal for all clients in care; no operational designated facility telephone; no designated responsible party present in facility; and administrator not present a sufficient number of hours to ensure facility is maintained and operating in compliance with regulation(s).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview was conducted with Facility Director. Copy of report discussed and provided to Facility Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/28/2025 01:58 PM - It Cannot Be Edited


Created By: Julie Florio On 01/28/2025 at 12:51 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: CONNECTED LIVING VACAVILLE
FACILITY NUMBER: 486803956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
85068.1(b)

1
2
3
4
5
6
7
Admission Procedures 85068.1(b)No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs....This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit a completed pre-placement appraisal for all clients in care to CCL by POC due date of 02/28/2025.
8
9
10
11
12
13
14
Based on oberservation, interview, and record review, Licensee did not comply in 4 out of 4 records reviewed where the pre-placement appraisal was missing from the clients' files, which poses a potetnial health, saftey, and/or personal rghts risk to clients in care.
8
9
10
11
12
13
14
Type B
02/28/2025
Section Cited
CCR85064(e)

1
2
3
4
5
6
7
85064 Adminstrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit an updated personnel report which shows the administrator scheduled to be present in the facility or update facility administrator to one who is able to oversee the facility to CCL by POC due date of 02/28/2025.
8
9
10
11
12
13
14
Based on observation, interview, and record review, Licensee did not comply as evidenced by incomplete client records and multiple deficencies which poses a potential health, safety, and/or personal rights risk to clients in care.
8
9
10
11
12
13
14
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/28/2025 01:58 PM - It Cannot Be Edited


Created By: Julie Florio On 01/28/2025 at 01:29 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: CONNECTED LIVING VACAVILLE
FACILITY NUMBER: 486803956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
85064(f)

1
2
3
4
5
6
7
85064 Administrator Qualifications and Duties (f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, ....This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit a signed LIC308 for the facility director to CCL by POC due date of 02/28/2025.
8
9
10
11
12
13
14
Based on observation, interview, and record review, Licensee did not comply as evidenced by the facility not having a designation of responsibility form signed and on file with CCL for the facility director which poses a potential health, safety, and/or personal rights risk to clients in care.
8
9
10
11
12
13
14
Type B
02/28/2025
Section Cited
CCR80073(a)

1
2
3
4
5
6
7
80073 Telephones
(a) All facilities shall have telephone service on the premises.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit self certification that they have fixed the facility telephone and will ensure that it is operational at all times moving forward to CCL by POC due date of 02/28/2025.
8
9
10
11
12
13
14
Based on observation and interview, Licensee did not comply in ensuring there is a designated, operational telephone in the facility at all times, which poses a potential health, safety, and/or personal rights risk to clients in care.
8
9
10
11
12
13
14
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3