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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804168
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:03:16 PM

Document Has Been Signed on 10/22/2024 01:03 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:SPECIAL CARE 4FACILITY NUMBER:
486804168
ADMINISTRATOR/
DIRECTOR:
AUJLA, MANJINDERFACILITY TYPE:
735
ADDRESS:1017 PINTAIL DRIVETELEPHONE:
(707) 981-1987
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Manjinder Aujla, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. There are 4 clients residing at this ARF, but all were attending day programs at the time. There were three staff on site at the time of inspection. LPA met with Facility Administrator, Manjinder Aujla and explained the purpose of the visit.
LPA Nakagawa and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restroom. LPA observed the facility to be clean, in good repair and odor-free. The bathroom has necessary grab bars, non-skid flooring, paper towels, trash can. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 107.2 F, within the required range. LPA observed fire extinguisher which was last serviced on 05/14/2024 and fully charged. Fire detectors, and carbon monoxide detectors were tested and functioning throughout the facility. LPA observed the first aid kit to be complete and ready for use. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of (4) four residents files and four (4) staff files which contained all the required documentation.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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