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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104577
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:38:28 PM

Document Has Been Signed on 02/14/2024 03:38 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:SENIOR DAY PROGRAMFACILITY NUMBER:
490104577
ADMINISTRATOR:CIMINO, MONTEFACILITY TYPE:
775
ADDRESS:25 HOWARD STREETTELEPHONE:
(707) 765-8490
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 20CENSUS: 8DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Director of Aging Well Together, Monte CiminoTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 12:55PM to conduct an Annual Required Inspection and was greeted by Staff. LPA and staff discussed the purpose of the visit. Director, Monte Cimino arrived shortly after.

LPA and staff initiated a tour of the facility at approximately 01:20PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in sinks accessible to clients measured at 114 and 113 degrees F which are within the range of 105-120 degrees F allowed per regulation. Cleaning supplies were located under the kitchen sink equipped with a lock. Facility has an outdoor area free from hazards with a shaded area. Facility does not handle medications or client cash resources. Clients were observed engaged in multiple activities throughout the visit. Facility has a kitchen to provide snacks to clients. Lunches are provided through an outside meal vendor service.

3 staff files and 5 client files were reviewed. Staff have required first aid. Client records indicated that Needs and Services Plans were being competed upon admission but not updated annually. During staff file review, LPA noted that Staff 1 (S1) was not background cleared.

Facility is conducting disaster drills per regulation, with the last one conducted on 01/08/2024. Fire extinguishers were last serviced 02/09/2024. Facility has smoke and carbon monoxide alarms that were tested and operational during visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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Document Has Been Signed on 02/14/2024 03:38 PM - It Cannot Be Edited


Created By: Helena Rummonds On 02/14/2024 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SENIOR DAY PROGRAM
FACILITY NUMBER: 490104577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(b)(1)(D)
Administration
(1) In addition to the applicant, this section is applicable to criminal record clearances and exemptions for the following persons: (D) Any staff person, volunteer, or employee who has contact with the clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff who are not background cleared which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee agrees to submit self certification stating that Staff 1 (S1) will be getting fingerprint cleared by POC due date of 02/14/2024. Staff 1 is to remain off site until fingerprints are cleared. Once fingerprints are read, licensee agrees to send proof of a cleared background check.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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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: SENIOR DAY PROGRAM
FACILITY NUMBER: 490104577
VISIT DATE: 02/14/2024
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Continued from LIC809

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Director. Signature on form confirms receipt of documents.

LPA is requesting the following to be submitted to CCL by 03/14/2024
LIC 500 (Personnel Report)
LIC 308 (Designation of Facility Responsibility)
LIC 9020 (Client Roster)
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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