<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804145
Report Date: 12/18/2024
Date Signed: 12/18/2024 02:04:35 PM

Document Has Been Signed on 12/18/2024 02:04 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:CLEMENT MANORFACILITY NUMBER:
486804145
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, FRANCIS A.FACILITY TYPE:
737
ADDRESS:7620 CLEMENT RD.TELEPHONE:
(415) 275-4262
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 0DATE:
12/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Marie Fernandez, Licensee and Ashley Fernandez, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/18/2024, Licensing Program Analyst (LPA) Nakagawa arrived announced for the purpose of conducting a pre-licensing inspection for a new Enhanced Behavioral Supports Home (EBSH) facility. LPA was met by Administrator Ashley Fernandez and Licensee Marie Fernandez.. The facility is on 2 acres in Dixon. There are currently no residents in care. The home consists of 4 bedrooms and 2 bathrooms with a kitchen; dining area; living room, family room and laundry room. All four bedrooms have the required furnishings. Medications are stored in a locked closet located off the living room. Fire inspection was successfully completed on 11/12/2024. The facility has 9 smoke and carbon monoxide detectors and 2 fire extinguisher, which is fully charged; one kept in kitchen and one in laundry room.

The facility was a comfortable temperature, free from obstructions and was well lit with night lights throughout the hallways and general areas. Extra hygiene products and linens were available. Water temperature measured approximately 108.9 degrees F which is within acceptable range of 105 to 120 degrees F. Cleaning products will be located in a locked cabinet under the sink or in storage in locked garage. Perishable and non-perishable foods were found to be stored in a safe manner and met the required minimum with a 7 day supply of non-perishable foods and 2 day supply perishable foods.

LPA found that the facility will utilize the MAR system. The Administrators and Lead Staff will ensure all medications are logged into the Centrally Stored Medication Record (CSMR).

Facility had all required postings displayed.

The facility has a nice yard, which is fenced for clients to enjoy time outside. There are chairs, a table and umbrella for clients and their visitors to use on days when the weather is dry.



Continued on 809-C....
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLEMENT MANOR
FACILITY NUMBER: 486804145
VISIT DATE: 12/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809....

Outside of the fenced area of the facility, the property has several storage buildings, which should be locked and secured; two were empty but one contained windows and building materials and garden tool. The property also has an old dilapidated barn and some old pipes and scrap metal which could be hazardous if clients were allowed access.

Component III Orientation was reviewed during today's visit. LPA Nakagawa will submit copy of the facility report to Santa Rosa Licensing Program Manager Mota and the CAB Application Analyst. Applicant will be contacted by the application analyst regarding the application status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2