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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801598
Report Date: 06/27/2024
Date Signed: 06/27/2024 12:23:49 PM

Document Has Been Signed on 06/27/2024 12:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NORTH BAY REHABILITATION SERVICESFACILITY NUMBER:
496801598
ADMINISTRATOR/
DIRECTOR:
VANDERGRIEND, LANDONFACILITY TYPE:
775
ADDRESS:5720 LABATH AVE, SUITE B & CTELEPHONE:
(707) 585-1991
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 60CENSUS: 22DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jesse Carbone-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), Alviso, conducted a Required -1 Year visit, on 6/27/24 at approximately 9:30am, and met with Administrator, Jesse Carbone, and Landon Vandergriend, Work Force Development Manager.

Day program has a fire clearance for sixty(60) capacity, which includes seven(7) non-ambulatory. Facility has a working carbon monoxide detector. During today's inspection the facility was operating with twenty-two (22) clients on-site.

The facility has a required infection control plan. The facility has a required emergency disaster plan, including evacuation plan.

The LPA reviewed six (6)staff files. All staff have criminal record clearance as required. All staff have First Aid and CPR certification. Staff have required training. The LPA reviewed six (6) client files. All the client files were found to be complete.

Hot water was checked at 113.7 degrees Fahrenheit, which is within regulation. The bathrooms were clean and orderly. Fire extinguishers were serviced and tagged as required. Facility has sufficient supply of cleaners/disinfectants, paper products, soap, and personal protective equipment (PPE) for use as needed. Cleaners/disinfectants were locked up and inaccessible to clients in care. The facility has a large first aid kit that is posted up on the wall. All exits were observed to be free and clear of obstruction.

There were no deficiencies cited today.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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