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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801598
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:19:55 PM

Document Has Been Signed on 05/10/2022 12:19 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:NORTH BAY REHABILITATION SERVICESFACILITY NUMBER:
496801598
ADMINISTRATOR:FREYMUTH THOMPSON, JAMIEFACILITY TYPE:
775
ADDRESS:5720 LABATH AVE, SUITE B & CTELEPHONE:
(707) 585-1991
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 60CENSUS: 10DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jamie Freymuth Thompson- TIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analysts (LPA), Dina Alviso conducted a 1 Year annual inspection, on 6/22/2021 at approximately 10:00am and met with Program Director Jamie Freymuth-Thompson. The inspection is focused on the Infection Control procedures and practices of this facility.

Currently the facility is operating with 10 clients on-site Mon -Tuesday and Thursday - Friday. The day program is also offering virtual day program as well; Currently there are 28 signed up for virtual day program only, with a total of 48 participating clients in day program services.

All five(5) staff on duty had required criminal record clearance, and all five(5) staff were vaccinated per record reviews.

The LPA was screened at the front door entry. All staff are covid-19 screened at the main office across the street from the day program. The LPA observed the facility's supply of personal protective equipment (PPE).The PPE supply was observed to be sufficient. The Director stated that there is a larger supply of PPE at the main office that the day program can access as needed. All exits were observed to be cleared of any obstructions.
Facility has an approved fire clearance for sixty (60) residents, of which seven (7) may be non-ambulatory. The facility has a reviewed mitigation plan.

Fire extinguishers were checked and four (4) out of five(5) were expired-dated 4/23/2021 when last serviced and tagged. This deficiency will be cited, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given.
Exit interview conducted with Director Jamie Freymuth.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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Document Has Been Signed on 05/10/2022 12:19 PM - It Cannot Be Edited


Created By: Dina Alviso On 05/10/2022 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NORTH BAY REHABILITATION SERVICES
FACILITY NUMBER: 496801598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
82020- Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing
fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [4] out of (5) fire extinguishers checked -the four checked were dated 4/23/21, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee to schedule to have the fire extinguishers serviced and tagged as required, ensuring to maintain the fire clearance as required by regulations. Submit plan of correction by 5/11/22; Submit proof of service completion to the fire extinguishers by 5/16/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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