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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804056
Report Date: 05/18/2023
Date Signed: 05/18/2023 05:51:09 PM

Document Has Been Signed on 05/18/2023 05:51 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: 3DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Charisma Mari, AdministratorTIME COMPLETED:
06:12 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Charisma Mari, Licensee and Administrator. Licensee Lily Rodriguez was also present.
LPA toured the facility, all exits were unobstructed. Fire extinguisher were charged and serviced 05/16/2023. The facility was found to be clean & at a comfortable temperature; screening station was observed at front entrance. LPA observed a supply of PPE, linens (bedding, towels, etc.), and cleaning solutions (observed locked & inaccessible). Liquid hand soap and paper towels are available in bathrooms. Facility food supply was within regulation and accessible to residents. Medication was centrally stored and locked. LPA discussed regulation 80075(k)(5) with Administrator.
Due to time constraint, LPA will return at a later date to review records and other items to complete inspection.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/19/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate

*LPA requested updated facility sketch and LIC200 for staff room fire clearance approval

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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