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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804106
Report Date: 06/21/2024
Date Signed: 06/21/2024 01:33:51 PM

Document Has Been Signed on 06/21/2024 01:33 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:INCLUSION SPECIALIZED PROGRAMS - DAWN WAYFACILITY NUMBER:
486804106
ADMINISTRATOR/
DIRECTOR:		AMBRIZ, PATRICIAFACILITY TYPE:
735
ADDRESS:2449 DAWN WAYTELEPHONE:
5623057599
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Particia Ambriz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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At approximately 8:40 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Maria Correa, House Manager. Administrator, Patricia Ambriz was contacted and arrived shortly after. Facility is an Adult Residential Facility with Ambulatory Developmentally Disabled Clients in care. LPA was informed that there are 4-clients in care; 1-client left for Day Program, and 3-clients were present during visit.

At approximately 9:00 AM, LPA initiated a tour of the facility with 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 and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered patio and seating area in the backyard with outdoor space for activities. LPA observed a supply of games for clients, a facility laptop available for client use, and an activity schedule. Facility has internet available to clients in care and the phone was tested an operable.

Facility's 2 fire extinguishers were observed charged and were last serviced November 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted June 2024. LPA observed facility's infection control plan which was updated January 2024 and emergency disaster plan which was updated during today's visit. Administrator also completed a Register of Facility Clients/Residents (form LIC9020) and agreed to post it with the facility emergency disaster plan. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid kit. Administrator states the facility does not have a backup generator.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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: INCLUSION SPECIALIZED PROGRAMS - DAWN WAY
FACILITY NUMBER: 486804106
VISIT DATE: 06/21/2024
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Continued from LIC809...

At approximately 10:15 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. Facility had the required paperwork for 4 of 4 clients. LPA advised Administrator to ensure all required documentation is signed and in client files for review upon request. Administrator and/or House Manager coordinate medical and dental visits for the clients and take them to their appointments.

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.

No deficiencies cited during today's inspection. Exit interview conducted with Administrator. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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