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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107871
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:47:55 PM

Document Has Been Signed on 08/25/2022 12:47 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Blanca Martinez-House ManagerTIME COMPLETED:
12:29 PM
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Licensing Program Analyst (LPA) Dina Alviso arrived to conduct a Required -1 Year inspection, and met with Lead caregivers, Blanca Martinez and Nancy Brasher. The inspection is focused on the Infection Control procedures and practices of this facility.

Administrator Sarah Lawrence is submitting the infection control plan today, per caregiver's conversation with the Administrator during the inspection. Caregiver Blanca provided the infection control plan from the facility binder for review. The infection control plan didn't have a date on it and/or a facility name. LPA requested Administrator to submit the Infection Control Plan, and the monkey pox addendum today, 8/25/22.

There were two(2) clients in care at the facility during this inspection; There were two(2) clients attending day program at the time of the inspection. All visitors and staff are screened upon entry; Temperatures are taken, and screening questions are asked before being allowed to remain in the facility. Clients are screened daily, and observed for any changes. All screenings are 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 posted up as required. Facility has a sufficient supply of personal protective equipment(PPE). Caregivers had a mask on as required; LPA observed both clients with masks on during the LPA's inspection. All smoke alarms were working properly during the LPA's inspection. There are two smoke alarms that include carbon monoxide alarms, these were working properly during the inspection.

No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with caregivers.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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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