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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490102164
Report Date: 11/08/2021
Date Signed: 11/08/2021 12:40:01 PM

Document Has Been Signed on 11/08/2021 12:40 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SEBASTOPOL DAY SERVICESFACILITY NUMBER:
490102164
ADMINISTRATOR:ANDERSON, LAURELFACILITY TYPE:
775
ADDRESS:167 NORTH HIGH STREETTELEPHONE:
(707) 525-0143
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 30CENSUS: 7DATE:
11/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Nancy Howard (Day Respite Coordinator) and Martha Kautz (Program Assistant)TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit. LPA met with Martha Kautz, Program Assistant and Nancy Howard Day Respite Coordinator. The program is open on Mondays and Wednesdays from 10am to 2pm.

The day program operates out of a primary room within the Sebastopol Senior Center. There are 2 common bathrooms available for participant use and exterior space. Facility is currently open and is providing day program services. Facility has posters through the facility and have a centralized sign-in location. Facility screens all participants, visitors and staff upon arrival and sign them in. Facility has a designated area to enter the facility, facility consists of a large area that has been modified, additional tables and chairs were removed to ensure social distancing between staff and participants. Facility has sufficient personal protective equipment for staff and participants including face shields, gloves, hand sanitizer and masks. Liquid dispensers were observed in the entrance. All bathrooms and surfaces in the facility will be sanitized after each use or at least every 3 to 4 hours, participants have the option of eating at the on-site dinning area. Meals are provided pre-packaged meals by Meals on Wheels. Facility has requested that participants or their responsible parties check the temperature of participants each morning. Facility does not provide transportation services. If a participant is exhibiting symptoms, they are to stay home and notify the facility. Staff have received training on PPE and additional training will be provided. 100% of staff and participants are vaccinated. Facility has submitted and approved their Mitigation Plan on 7/20/21. LPA had technical difficulties pulling out the infection domain and contacted IT services and was informed that they need to work on issues when LPA is back to the office. LPA provided a printed copy to Day Respite Coordinator during this visit.

During today's visit LPA requested the following documents to be submitted to CCL by 11/19/21: Administrative Organization (LIC309) and Personnel Record (LIC501).
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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