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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801563
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:43:23 AM

Document Has Been Signed on 03/28/2024 10:43 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: 38DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:James Cox (Executive Director)TIME COMPLETED:
10:58 AM
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Licensing Program Analyst, (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Chief of Services, Paula Finley. Executive Director, James Cox arrived later. The day program is open Monday through Friday from 8:00am to 4:00pm. Required postings were observed.

LPA/staff initiated a tour of the buildings and grounds at approximately 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Bathrooms used by participants were sanitary and in good repair. Water temperature in bathrooms used by participants read at 100.9, 106.2, 106.7, 111 which are within regulation of 105 and 120 degrees F. Toxins will be located in a janitorial closet which will be kept locked. In the hallway near the kitchen there are designated lockers for participants to store their items. Knives and other items that could pose a risk were locked. Participants bring their own lunch and those who stay at the facility during the day eat in the lunchroom or in common areas. Refrigerators for participant lunches were clean. Medication is centrally stored and locked in the support team office. The facility does not handle medications. Fire extinguisher was last inspected 3/8/2024. 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 3/8/24. Facility provides transportation for some participants. Facility van contains a first aid kit and fire extinguisher was charged and serviced. First aid kit is fully stocked. Last disaster drill was conducted on 1/25/24.

LPA initiated file review at 10:00 am, five staff and ten participant files were reviewed. Staff have required First Aid and CPR training. Participants records are updated. The facility doesn't handle cash resources.

Facility will provide updated copies of the following documents by 4/5/24: Designation of Responsibility (LIC308) and Personnel Report (LIC500).
No deficiencies cited during this inspection. Exit interview conducted with Executive Director and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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