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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804056
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:00:52 PM

Document Has Been Signed on 05/23/2024 02:00 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:FALCON HIGHFACILITY NUMBER:
486804056
ADMINISTRATOR/
DIRECTOR:		MARI, CHARISMA NIEVESFACILITY TYPE:
735
ADDRESS:2044 FALCON CTTELEPHONE:
(707) 438-9210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Charisma Nieves Mari, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Licensee, Liliana Rodriguez and LIcensee/Administrator, Charisma Nieves Mari. Facility is an Adult Residential Facility with Ambulatory Developmentally Disabled Clients in care. LPA was informed that there are 4-clients in care; 2-clients were away at Day Program, and 2-clients were present during visit.

At approximately 9:50 AM, LPA initiated a tour of the facility with Licensee/Administrator and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food but does not have one week of non-perishable foods. LPA informed Licensee/Administrator of the need to increase facility's supply of non-perishable and emergency food. Medications were centrally stored and locked. There is a covered deck and outdoor space for activities in the backyard. LPA observed puzzles and a supply of games for clients.

Facility's fire extinguisher was last serviced May 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular quarterly disaster drills, and the most recent drill was conducted April 2024. LPA observed the facility's infection control plan and emergency disaster plan, which are both reviewed and updated annually. LPA observed an insufficient emergency supply of water and advised Licensee/Administrator to increase the facility's supply. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid kit. Licensee states facility has a back-up battery if one is needed.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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: FALCON HIGH
FACILITY NUMBER: 486804056
VISIT DATE: 05/23/2024
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Continued from LIC809...

At approximately 10:50 AM, LPA reviewed 5 staff files and 4 client files. 5 of 5 staff files reviewed have the required First Aid certificates. Each has current CPR certification as well. LPA observed that 5 of 5 staff files have all the required paperwork in their files, however 1 of 5 files reviewed had a LIC-501 Personnel Record/Job Application not signed or dated by the staff member. LPA advised Licensee/Administrator to have the staff member sign and date this document. 4 of 4 client files had all the required paperwork per regulation. Licensees manage medical and dental visits for the clients and take them to their appointments unless the clients' family chooses to take them.

At approximately 12:30 PM, LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:

LIC501 - Signed Personnel Record/Job Application
Proof of increased non-perishable food supply
Proof of increased emergency water supply

Exit interview conducted with Licensee whose signature on this document confirms receipt. No Deficiencies were cited. This report was reviewed with Licensee.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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