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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800482
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:24:15 PM

Document Has Been Signed on 06/04/2024 02:24 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/
DIRECTOR:
LOEWEN, VICKIEFACILITY TYPE:
735
ADDRESS:140 CHERIE WAYTELEPHONE:
(707) 528-2088
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 3DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Russell Loewen (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:39 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee, Russell Loewen. Fees are current. Clients were attending day program. Contact information was reviewed. Required postings were observed.

LPA/Licensee initiated a tour of the facility at 1:00 pm and observed the following: Facility was a comfortable temperature and passageways were free from obstruction. Client rooms were furnished per regulation. Water temperature in client bathroom read at 115.3 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins were stored in a locked cabinet in the laundry room and a locked cabinet under the kitchen sink. Fire extinguishers were last inspected July, 2023. Facility has a fire pull system. Four smoke detectors and one carbon monoxide detector were tested and operational. Most recent Fire/Disaster drill was conducted April 30, 2024. Facility does have a current activity and menu calendar.

LPA initiated file review at 1:20 pm. Three client and three staff files were reviewed. First aid certificates for staff are current. Administrator Certificate for Vickie Loewen, 6022472735 expires 12/8/2024. Medication and medication records were reviewed. Cash resources were reviewed along with transaction documentation. Medications are centrally stored and locked.

LPA obtained updates of the following documents: LIC308 (Designation of Responsibility), LIC500 (Personnel Report), LIC400 (cash affidavit) 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: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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