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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800482
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:54:34 PM

Document Has Been Signed on 04/28/2022 02:54 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:CHERIE WAYFACILITY NUMBER:
496800482
ADMINISTRATOR:LOEWEN, VICKIEFACILITY TYPE:
735
ADDRESS:140 CHERIE WAYTELEPHONE:
(707) 528-2088
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 3DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ryan Loewen (Staff)TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Ryan Loewen. Licensee, Vickie Loewen was not able to come to the facility but was available by phone and gave authorization for staff to sign the report. Licensee informed LPA that they have reviewed PIN 22-05, PIN 22-06, PIN 22-07 and PIN 22-09.

LPA arrived at the facility and have their temperature checked and logged into a sign-in sheet. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least two times a day. Facility is allowing indoor visitations and has antigen tests available to use for visitors. Facility is able to accommodate a single room for each client that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and has been N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has 100% vaccination rate and boosters for all staff and clients. Two out of three clients do attend to day program three days per week and one out of three clients do attend to day program once per week and the facility also provides activities. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has submitted their Covid Mitigation Plan and approved on 7/7/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.

Facility provided updated copies of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E), affidavit regarding client/resident cash resources (LIC400) and surety bond. No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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