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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804044
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:14:26 PM

Document Has Been Signed on 03/11/2025 12:14 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:KREATIVE COMMUNITY SERVICES - BLOOMFACILITY NUMBER:
486804044
ADMINISTRATOR/
DIRECTOR:		ALOE, SHAYNEFACILITY TYPE:
775
ADDRESS:1241 ALAMO DRIVE SUITE 7TELEPHONE:
(707) 474-9653
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 60CENSUS: 14DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Andrea Cervantes, ManagerTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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At approximately 9:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct an annual required inspection for this facility and met with Manager Andrea Cervantes. Kreative Community Services - Bloom is licensed to serve 60 ambulatory or non-ambulatory clients ages eighteen (18) and older as an Adult Day Program. At the time of the visit the facility had fourteen (14) clients. The facility runs on staggered scheduling. At approximately 10:20 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation.

LPA continued with a tour of the facility with Manager Cervantes. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were found to be last inspected on 12/11/2024. Carbon monoxide detector was tested and found to be in working order. The fire safety inspection was conducted on 1/10/2025 for all exits, safety devices including sprinklers, alarms and smoke detectors. Emergency disaster drills are conducted monthly, with the last drill conducted 3/5/2025.

Clients were observed to be engaged in various group activities including, discussion, arts & crafts, and other options to choose during classroom hours. Clients were observed to have positive relationship with staff continuously engaging and participating with clients. LPA was informed that clients currently provide their own meals with snacks. All toxins/cleaners were locked and inaccessible to clients in care. Hot water temperatures for a sample size of four (4) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Continued on 809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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: KREATIVE COMMUNITY SERVICES - BLOOM
FACILITY NUMBER: 486804044
VISIT DATE: 03/11/2025
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...Continued from 809

LPA conducted a sample file review of five (5) staff members. All staff members had appropriate documentation, proof of training, education and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for five (5) clients. All clients' files were observed to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to clients in care. LPA conducted a spot check of clients’ medications and observed medications to be centrally stored and all documentation and medications to be in order. Personal and Incidental monies are not kept by the facility.

LPA is requesting the following documents submitted to CCLD by 4/11/2025:

LIC 500 Personnel Report


LIC 610D Emergency Disaster Plan

No deficiencies cited during today's visit.

Exit interview conducted. Copy of report discussed and provided to Manager Cervantes. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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