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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804045
Report Date: 08/12/2022
Date Signed: 08/12/2022 11:54:58 AM

Document Has Been Signed on 08/12/2022 11:54 AM - 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:KEARNEY COMMUNITY SUPPORT HOMEFACILITY NUMBER:
486804045
ADMINISTRATOR:COLEMAN, CLARENCE JR.FACILITY TYPE:
735
ADDRESS:100 KEARNEY WAYTELEPHONE:
(707) 548-3646
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 0DATE:
08/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Clarence Coleman JrTIME COMPLETED:
12:15 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 Analyst (LPA) A. Canela conducted a pre-licensing inspection and was greeted by Applicant, Clarence Coleman Jr. who will be the Administrator (Administrator Certificate 6063001735 exp 5/15/2024) This pre-licensing inspection is being conducted as an initial facility application.

This facility is a single story home, with 4 client bedrooms, 2 bathrooms, staff room, office room, Living room, dinning room, and kitchen. The Vacaville Fire Department granted this facility a fire clearance on 2/16/2022 for 4 ambulatory clients. There are currently 0 clients in care. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. The home was observed organized and at a comfortable temperature. Fire extinguisher was charged and current. Emergency Lights, Smoke detectors and carbon monoxide detectors were present and operational. Exits were observed to be unobstructed. The Applicant has submitted their Mitigation plan, and will be mailing their infection control plan to LPA. Fireplace was appropriately screened.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· Supply of linens, paper products, and hygiene supplies available
· Complete first Aid kit, night-lights, and flashlights for emergency lighting
· Required furnishings and linens in all 4 bedrooms
· The water temperature was tested during inspection an within the required 105 to 120 degrees F

Pre-licensing is complete and this facility has no corrections needed, no deficiencies.
The Component III Orientation was completed with applicant during this visit.

LPA will submit the pre-licensing inspection report to Application Unit Analyst in Sacramento who will notify applicant of application status.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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 1