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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804263
Report Date: 08/01/2024
Date Signed: 08/01/2024 05:53:02 PM

Document Has Been Signed on 08/01/2024 05:53 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:SPECIAL CARE ADULT RESIDENTIALFACILITY NUMBER:
486804263
ADMINISTRATOR/
DIRECTOR:		AUJLA, HARJITFACILITY TYPE:
735
ADDRESS:425 MARINA BLVDTELEPHONE:
(707) 981-1987
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 0DATE:
08/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Harjit Aujla, LicenseeTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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At approximately 3:50 PM, Licensing Program Analyst (LPA) Julie Florio arrived announced to conduct a pre-licensing inspection and was greeted by Licensee/Applicant's spouse. Harjit Aujla, Licensee/Administrator arrived shortly after. This pre-licensing inspection is being conducted for a change of location licensing of an Adult Residential Facility (ARF). Fire Clearance has been approved for 4 ambulatory clients. Licensee/Applicant is currently in partnership with North Bay Regional Center (NBRC).

LPA spoke with Licensee on the phone on 7/15/2024 and confirmed the moving plan. Licensee states the facility will hire help for the move and plans to move everything and the clients over the course of one day. Licensee is coordinating with the North Bay Regional Center (NBRC) and was told the tentative move date is scheduled for 9/1/2024. As a backup plan, Licensee plans to place clients in a hotel for the night if needed. LPA, Marisol Cuarda completed inspection of all facility furnishing and equipment at current location: 415 Honker Lane, Suisun, CA 94585 on 8/1/2024 and confirmed that all were within regulation.

At approximately 4:00 PM, LPA, Julie Florio initiated a tour of the new facility 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. Licensee states telephone service and internet service will be transferred from current location to this new location. Licensee agrees to submit proof of a scheduled telephone and internet installation date for facility. Licensee states facility has two tablets and laptop available for client use.

Facility has a fully charged fire extinguisher, which was last inspected June 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

No staff are currently associated to the facility. Licensee has been informed of association and staff transfer process.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPECIAL CARE ADULT RESIDENTIAL
FACILITY NUMBER: 486804263
VISIT DATE: 08/01/2024
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...continued from LIC809...

The backyard features paved walkways and a patio with a shaded seating for client outdoor use. Windows, screens, and blinds are all found to be in good repair and facility exits are clearly identified.

Licensee/Applicant to submit a copy of the facility's proof of ownership and will submit proof of liability insurance upon licensure.

Component III orientation was conducted with the Licensee/Applicant at facility. Licensee/Applicant conveyed knowledge and understanding of Title 22 regulations. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.

Exit interview conducted with Licensee/Applicant, whose signature on this document confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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