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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107871
Report Date: 08/20/2021
Date Signed: 08/20/2021 06:48:27 PM

Document Has Been Signed on 08/20/2021 06:48 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:SARAH'S GROUP HOME FOR YOUNG ADULTSFACILITY NUMBER:
490107871
ADMINISTRATOR:LAWRENCE, SARAHFACILITY TYPE:
735
ADDRESS:8019 ADRIAN DRIVETELEPHONE:
(707) 795-9701
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 4DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:40 PM
MET WITH:Cozy Edmondson-CaregiverTIME COMPLETED:
06:50 PM
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Licensing Program Analyst (LPA) Dina Alviso arrived to conduct an 1 YR Required inspection, and met with caregiver Cosey Edmondson. The inspection is focused on the Infection Control procedures and practices of this facility.

Mitigation plan was reviewed by the Department on 8/11/21.

There were 4 clients in care at the facility during this inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Clients are screened daily, and observed for any changes, all information is logged.

Facility was found to be clean, orderly, and at a comfortable temperature with exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications are stored locked making them inaccessible to clients in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Caregiver had a mask on during the LPA's inspection. LPA observed clients with masks on when in facility common

No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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