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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801563
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:46:10 AM

Document Has Been Signed on 02/24/2023 11:46 AM - 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:BECOMING INDEPENDENT-SANTA ROSAFACILITY NUMBER:
496801563
ADMINISTRATOR:COX, JAMESFACILITY TYPE:
775
ADDRESS:1455 CORPORATE CENTER PKWY.TELEPHONE:
(707) 524-6600
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 285CENSUS: 68DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Paula Finley (Chief of Services)TIME COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Paula Finley (Chief of Services). This inspection is based on infection control practices at this facility. Currently the facility is operating with 68 participants on-site Monday-Friday between 8:00am to 4:00pm.

The building is housing some administration offices, changing rooms, lunchroom, multiple areas used for activities and staging areas for participants who go out into the community. Facility was a comfortable temperature and passageways were free from obstructions. Facility has two centralized sign-in system located at loading area and facility entrance where facility documents staff, visitors and participants. Facility provides transportation services by R&D for some participants that ensures to follow current guidelines. Participants bring their own snacks and lunches. Staff was observed wearing a mask while in the facility. Participants wear face coverings as tolerated. All staff continues receiving required training on infection control, but they have not been N95 fit tested. Regular maintenance plan includes sanitizing and cleaning after conclusion of each activity. Facility has automated dispensers to dispense hand sanitizer. Facility has submitted their Mitigation Plan and Infection Control Plan for CCL's review. Facility has posters that are posted through the facility encouraging participants to wear a mask, wash their hands, cough etiquette and maintain social distancing. Facility has sufficient personal protective equipment for staff and participants including gloves, hand sanitizer and masks. Last disaster drill was conducted on February 8, 2023, Fire extinguisher was last inspected April 2022. Facility smoke alarms and carbon monoxide detectors are hard wired and inspected and maintained by a vendor. Most recent inspection from the local fire department was conducted 11/21/2022. Medication is centrally stored and locked in the support team office.

Facility will provide updated copies of the following documents by 3/6/23: Designation of Responsibility (LIC308) and Personnel Report (LIC500). Exit interview was conducted with Chief of Services and a copy of this report was given.
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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