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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490104577
Report Date: 02/11/2025
Date Signed: 02/11/2025 03:49:03 PM

Document Has Been Signed on 02/11/2025 03:49 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/
DIRECTOR:		CIMINO, MONTEFACILITY TYPE:
775
ADDRESS:25 HOWARD STREETTELEPHONE:
(707) 765-8490
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 20CENSUS: 13DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Elece Hempel, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analysts (LPAs), Stevenson and Loera, conducted a Required 1-Year visit, on 02/11/2025 at approximately 12:45pm; LPAs met with Elece Hempel, Executive Director. There are 13 clients enrolled in the day program. Facility has fire clearance for 20 clients in which 8 can be non-ambulatory. The program is open Mondays, Wednesdays, and Fridays from 10am to 2pm.

LPAs reviewed 1 executive director (non-hands on care role) and (4) staff files. Staff were found to have required documents and TB clearance. All staff have criminal record clearance as required. Staff had required first aid, and CPR certification. Staff had required training.
Fire/emergency drills are conducted quarterly per review of the emergency binder with last drills conducted Sept 2024. Fire extinguishers were charged and last inspected 02/2025.
LPAs toured the facility with Elece Hempel, executive director. Staff were running a caregiver support group with no current clients in house. The facility was observed to be at a comfortable temperature clean and orderly during the inspection.

LPAs observed toxins to be stored inaccessible to clients in care. LPAs observed that no medications were held on site and told that help with prescribed or PRN meds are not performed at the day program. Program does not handle client cash. Bathrooms were clean and had paper towels. Kitchen and two bathroom sinks were measured to have water temps between 105 and 120 as required by title 22 regulations.
All exits were unobstructed.

Senior Day Program provides meals that are delivered by Meal on Wheels. Program has a nutritious menu that is rotated monthly, as well as, daily activities including, but not limited to story time, exercise, live music, bingo, games, art and interaction will local school children etc which are rotated monthly with new activities scheduled.

Report continued on LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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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: 02/11/2025
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Licensee to submit the following updated annual forms by 03/11/2025.

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Emergency Disaster Plan- updated & reviewed if needed- submit copy if changes
Infection Control Plan-updated & reviewed if needed- submit copy if changes

No deficiencies cited today.

Exit interview conducted with Elece Hempel, Executive Director.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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