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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490102164
Report Date: 12/19/2022
Date Signed: 12/19/2022 09:44:23 AM

Document Has Been Signed on 12/19/2022 09:44 AM - 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:SEBASTOPOL DAY SERVICESFACILITY NUMBER:
490102164
ADMINISTRATOR:DUFFY, REBECCA JFACILITY TYPE:
775
ADDRESS:167 NORTH HIGH STREETTELEPHONE:
(707) 525-0143
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 30CENSUS: 7DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Rebecca Duffy (Administrator)TIME COMPLETED:
09:59 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Rebecca Duffy. The inspection is focused on the Infection Control procedures and practices of this facility. 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 has posters through the building and have a centralized sign-in location. Facility screens all participants, visitors and staff upon arrival and sign them in. LPA was screened when arrived and results were documented on a checking log binder. The 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 gloves, hand sanitizer and masks. Liquid dispensers were observed in the entrance. All bathrooms and surfaces in the facility are sanitized at least two times per day, participants have the option of eating at the on-site dinning area. LPA observed that staff were wearing masks during this visit, 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. Staff have incorporated training on infection control and donning and doffing of Personal Protective Equipment (PPE) into their regular training schedule. Fire extinguishers were last serviced July 2022. Facility is located in a building and the fire system is monitored and maintained by the landlord. Administrator and LPA discussed their Emergency Disaster Plan, Mitigation Plan and Infection Control Plan.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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