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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800482
Report Date: 05/24/2023
Date Signed: 05/24/2023 02:29:17 PM

Document Has Been Signed on 05/24/2023 02:29 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:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Russell Loewen (Licensee)TIME COMPLETED:
02:44 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Russell Loewen. At the time of visit, all clients were attending to Day Program.

Upon arrival, LPA confirmed with Licensee that they are following current Covid19 and masks guidance. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 109.1 which are within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet under the kitchen sink. Fire extinguishers were last inspected June 2022. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 2/27/23. Facility has a fire pull system and it was last inspected by Santa Rosa Fire Department on June 2022. Required postings were observed. Emergency supplies were observed including flashlights and water. Facility does have a current activity and menu calendar. First aid kit was fully stocked.

LPA initiated a file review at 1:30 pm. Three client and four staff files were reviewed. Clients records have updated care plans on file. First aid certificates for staff are current. Administrator Certificate for Vickie Loewen 6022472735, expires 8/30/2024. Medications and medication records were reviewed. Cash resources and documentation were reviewed. Medications are centrally stored and locked.

LPA obtained updates of the following documents: LIC308 Designation of Responsibility, LIC500 (Personnel Report), LIC400 (cash affidavit for clients), LIC610E Emergency Disaster Plan and surety bond.

No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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