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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111253
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:31:51 PM

Document Has Been Signed on 08/08/2023 01:31 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:A STEP UPFACILITY NUMBER:
490111253
ADMINISTRATOR:MOORE, SHANICEFACILITY TYPE:
772
ADDRESS:420 EAST COTATI AVENUETELEPHONE:
(707) 795-4336
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY: 12CENSUS: 7DATE:
08/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Director, Debbie McCullochTIME COMPLETED:
01:45 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 year Visit and met with Program Director, Debbie McCulloch. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health and Substance Abuse Disorders. Facility has an approved fire clearance and capacity for 12 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 7 clients in care and 2 staff members on-site.

At approximately 9:15AM, LPA conducted a walk through of the facility. Hot water temperatures for all sinks in the facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPA observed that there were two locked closets and two locked freezers located in the facility's Annex. Per Program Director, these closets and freezers are where they store emergency food and bulk items. All Clients have access to food, snacks, and drinks in the main house. LPA confirmed that the locked closets and freezers store the facility's extra food and bulk supplies.
LPA observed that the master bedroom located in the main house currently has 3 Clients residing in the bedroom. Title 22 Regulation states that there may be no more than 2 clients to a bedroom, unless documentation is submitted to the Department for review and approval. Per Program Director, the third bed was located in the Annex, but was moved to the master bedroom to be compliant with Department of Public Health's COVID-19 requirements. LPA and Program Director discussed submitting documentation to Community Care Licensing (CCL) for review and approval to have 3 Clients to a bedroom. Facility to relocate the third bed back to the Annex while document review is in process (See Technical Advisory 81087(e)(1).

At approximately 9:40AM, LPA reviewed a sample size of 6 Client and 6 Staff Files. Client Files were all found to be well organized, thorough and contained the required documentation. Client P&I monies were documented, secure and not commingled. Review of Staff Files indicated that staff had First Aid and CPR certification. Training for 2023 was shown to be ongoing and being conducted appropriately. 1 of 6 Staff Files were shown to not have a health screening report or TB test on file (See Technical Advisory 81066(c)(10) and 81066(c)(11).
At approximately 11:45AM, LPA reviewed a sample size of 4 Client medication records. Medication was observed to be centrally stored and secure.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A STEP UP
FACILITY NUMBER: 490111253
VISIT DATE: 08/08/2023
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Continued from LIC809

At approximately 12:30PM, LPA conducted Staff and Client interviews.

Facility is changing Administrator duties to Debbie McCulloch. LPA is requesting the following Administrator paperwork:
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)
Administrator Documents to be submitted to CCL by due date of Friday, 08/18/2023.

LPA is requesting the following documents to update the facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610D)
  • Updated Personnel Report (LIC500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC9020)
  • Updated Liability Insurance
  • Updated Lease
Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Tuesday, 09/05/2023.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Advisories) discussed and provided to Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
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