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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804045
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:36:07 PM

Document Has Been Signed on 08/11/2023 12:36 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: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: 2DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Clarence Coleman, Jr. AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Inspection and was greeted by Administrator Clarence Coleman Jr. (Administrator Certificate 6063001735 exp 5/15/2024).

This facility is clean and well-organized. All 4 client bedrooms are well-appointed with the required furnishings and linens as per regulation. The facility provides hygiene items to the clients. There are currently 2 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. The kitchen was clean and organized. The refrigerator and freezer were well-stocked with fresh foods. Pantry was well-stocked with non-perishables. Emergency lights, smoke detectors and carbon monoxide detectors were present and operational. Exits were observed to be unobstructed. The Administrator has submitted their Mitigation plan and their Infection Control Plan; updates to be submitted. Fireplace was appropriately screened. The living room is homey and comfortable.

The outside area has 2 sheds; both containing household items and tools. The residents have a wonderful backyard with comfortable seating and shaded areas, and a ping pong table.

There were no deficiencies found at the time of inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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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