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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804056
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:47:31 PM

Document Has Been Signed on 05/12/2022 03:47 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:FALCON HIGHFACILITY NUMBER:
486804056
ADMINISTRATOR:MARI, CHARISMA NIEVESFACILITY TYPE:
735
ADDRESS:2044 FALCON CTTELEPHONE:
(707) 438-9210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
05/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Applicant Charisma MariTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Karina Canela conducted an announced pre-licensing inspection on 05/12/2022.
LPA met with Applicant Charisma Mari, who will be the Administrator once the facility is approved for licensure. Additionally Liliana "Lily" Roque was present. The facility has a fire clearance approval from the Fairfield Fire Department for a total capacity of 4 Ambulatory clients (the facility does not have approval for non-ambulatory or bedridden). Facility does not have a fire clearance approval from the Fairfield Fire Department or an approved waiver from Community Care Licensing for a secured perimeter. Applicant understands they may not lock the backyard gate without prior approval. Facility will operate with 24/7 staffing (staff room available) and Licensee will ensure sufficient staffing at all times.
LPA obtained a copy of surety bond during inspection.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station; LPA was screened upon arrival.
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed; 1 Fire Extinguisher charged and serviced 03/05/2022
· 7 smoke detectors and 1 carbon monoxide detector, which were tested and observed operational
· Complete first aid kit, night-lights leading to bathroom, and flashlight for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Required furnishings in all 3 client bedrooms
· Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, sample food menu calendar).
· The water temperature was tested during inspection and was within regulation of 105 - 120 Degrees F

The Component III Orientation was completed; Pre-licensing is complete with no corrections needed. LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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