<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801313
Report Date: 04/14/2023
Date Signed: 04/14/2023 05:53:28 PM

Document Has Been Signed on 04/14/2023 05:53 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:
04/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Caregiver Sandra KruseTIME COMPLETED:
05:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alviso arrived to conduct an annual continuation visit, on 4/14/23 at approximately 3:25pm, and met with caregiver Sandra Kruze. The LPA started the annual visit on 3/21/23, and had met with the Administrator, see LIC809. The facility has submitted the required infection control plan.

There are four(4) clients in care at this facility, all are ambulatory. The clients all attend day programs, currently there are two(2)clients in the home. The other two(2) were out in the community. Client files were reviewed and found to be complete.

LPA reviewed staff files. All staff have criminal record clearance as required. Staff have required training. Administrator Lindsey has an Adult Residential Administrator Certificate, #6017082735, expires 5/27/24.

LPA toured the facility, LPA observed that the fire extinguishers, two(2), are tagged and serviced as required, expires 10/13/23. All exits were unobstructed. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 110.5 degrees F. which is within regulations.
Facility has a sufficient supply of food for clients' in care. Facility has a sufficient supply of cleaners/disinfectants and paper products. Facility had sufficient lighting, dishware, hygiene products, and furnishings for resident use. LPA observed that the utilities were on, and working properly. during the visit. LPA observed that the common areas were cleaned and organized; LPA observed that the garage space was cleaned and organized.

Continued on LIC809C..
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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 2
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: SARAH'S YOUNG ADULT HOME
FACILITY NUMBER: 496801313
VISIT DATE: 04/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility has a sufficient supply of personal protective equipment(PPE) for use as needed. All medications were locked up and inaccessible to clients in care. All toxins/disinfectants/cleaners were locked up and inaccessible to clients in care. The backyard was clean and orderly.

LPA requested the following updated records to be submitted to Community Care Licensing by 05/14/2023:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· Copy of current- Administrator's Certificate
· LIC 610D Emergency Disaster Plan
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond (ensure surety bond is in required amount per LIC400)
· Copy of Infection Control Plan(if there are changes)

There were no deficiencies cited during today's inspection.
Exit interview conducted with caregiver Sandra Kruze.
Report left with Caregiver Kruze for the Administrator Lindsey Gregori.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2