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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804106
Report Date: 06/23/2023
Date Signed: 06/23/2023 09:11:30 PM

Document Has Been Signed on 06/23/2023 09:11 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:INCLUSION SPECIALIZED PROGRAMS - DAWN WAYFACILITY NUMBER:
486804106
ADMINISTRATOR:BALDWIN, VANESSA M.FACILITY TYPE:
735
ADDRESS:2449 DAWN WAYTELEPHONE:
(562) 305-7599
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
06/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jose Hernandez, Regional DirectorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted a pre-licensing inspection and met with Jose Hernandez, Regional Director. A Fire clearance was granted by the City of Fairfield Fire Prevention on 10/17/2022 for 3 ambulatory and 1 non-ambulatory clients.

LPA toured facility and observed: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations and food was stored properly. Facility is a one floor residence with 4 client bedrooms that were observed furnished per regulation. Facility will have awake staff at night. There is a phone line designated for client use. There were an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Hot water temperature checked between 109 - 110 degrees F. Fire extinguisher was charged and serviced on 11/23/2022 and within regulation. Smoke alarms and carbon monoxide were operational during inspection. Personnel records and clients records are stored at the facility.

The main floor includes office area, living room area, two bathrooms, dinning room, kitchen, laundry room, garage and client's bedrooms. Activities calendar is posted for facility activities and individual activities. Medication is centrally stored and locked in kitchen cabinet, and toxins are locked under the kitchen sink and in the laundry room.

Component III orientation was conducted with Regional Director, Jose Hernandez.
"Pre-Licensing is complete, and this facility had no deficiencies" LPA will notify Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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