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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804014
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:22:46 PM

Document Has Been Signed on 01/17/2024 12:22 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:ZAMORA FAMILY HOMEFACILITY NUMBER:
486804014
ADMINISTRATOR:POWELL, JENNIFERFACILITY TYPE:
735
ADDRESS:116 SUNSET AVE.TELEPHONE:
(510) 828-1019
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 3CENSUS: 0DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jennifer Powell AdministratorTIME COMPLETED:
12:44 PM
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01/17/2024 10:30 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Jennifer Powell (cert # 6020036735 exp.10-21-24) and explained the purpose of the visit. Administrator certificate is current. The facility has no residents at this time.

LPA Benson and the administrator toured the facility together to ensure the health and safety of residents. Areas toured include but are not limited to two (2) resident rooms, three (3) staff rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff files were reviewed.



Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has a locked closet for client medication.

First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises.

No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to Administrator Jennifer Powell.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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