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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801598
Report Date: 06/06/2023
Date Signed: 06/06/2023 01:57:41 PM

Document Has Been Signed on 06/06/2023 01:57 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:VANDERGRIEND, LANDONFACILITY TYPE:
775
ADDRESS:5720 LABATH AVE, SUITE B & CTELEPHONE:
(707) 585-1991
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 60CENSUS: 24DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Landon Vandergriend-AdministratorTIME COMPLETED:
02:10 PM
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Licensing Program Analyst(LPA), Alviso conducted a Required 1- Year visit, on 6/6/23 at approximately 9:35am, and met with Administrator Landon Vandergriend.

Day program has a fire clearance for sixty(60) capacity, which includes seven(7) non-ambulatory. Currently the facility is operating with twenty-four(24) clients on-site Monday through Friday. The facility has a required infection control plan. The facility has a required emergency disaster plan, including evacuation plan.
The LPA reviewed five staff files. All staff have criminal record clearance as required. All staff have First Aid and CPR certification. LPA reviewed staff training. The LPA reviewed 5 client files. All the client files were found to be complete.

The LPA observed a screening area, in the front of the facility as you enter the building, for use as needed. The LPA observed the facility's supply of personal protective equipment (PPE) for use as needed. Hot water was checked at 107.F which is within regulation. All exits were observed to be cleared of any obstructions. All five(5) fire extinguishers were serviced and tagged as required-expires 5/1/24. Three carbon monoxide detectors were checked and working properly during the inspection. Facility has a 72 hour shelter in place supply of food and water. All day program vehicles are stocked with a First Aid kit. The facility had a First Aid bag, and a large mounted First Aid metal cabinet, with all required supplies. The facility was observed to have two(2) program classes being conducted with clients in care during the inspection. Facility was observed to be at a comfortable temperature. The facility has a kitchen area with appliances, and some snack items; The facility was observed to be clean and orderly.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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