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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801313
Report Date: 03/21/2023
Date Signed: 03/21/2023 05:19:33 PM

Document Has Been Signed on 03/21/2023 05:19 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 YOUNG ADULT HOMEFACILITY NUMBER:
496801313
ADMINISTRATOR:GREGORI, LINDSEYFACILITY TYPE:
735
ADDRESS:1520 GRIFFIN WAYTELEPHONE:
(707) 585-6223
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 4DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Lindsey Gregori-AdministratorTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Alviso arrived to conduct a Required 1-Year visit, and met with Administrator Lindsey Gregori. There are four(4) clients in care at this facility, all are ambulatory.

The clients all attend day program, all but one(1) was home at the facility. LPA reviewed staff and client files. All staff have criminal record clearance as required. Staff have training as required by regulation. Administrator Lindsey has an Administrator Adult Residential Certificate, #6017082735, expires 5/27/24. Client files were reviewed and found to be complete.


LPA toured the facility with the Administrator Lindsey. Fire extinguishers, two(2), are tagged and inspected as required, expires 10/13/23. All exits were unobstructed. Facility has a sufficient supply of food. Facility has a sufficient supply of cleaners/disinfectants and paper products. The facility has a sufficient supply of personal protective equipment(PPE).

This inspection will be continued by the LPA.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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