496801598-5-15-2025-21-AS-DALO-DGPSZ4-20250515141830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801598
Report Date: 05/15/2025
Date Signed: 05/15/2025 02:18:39 PM

Document Has Been Signed on 05/15/2025 02:18 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 SERVICES		FACILITY NUMBER:	496801598
ADMINISTRATOR/ DIRECTOR:	VANDERGRIEND, LANDON		FACILITY TYPE:	775
ADDRESS:	5720 LABATH AVE, SUITE B & C		TELEPHONE:	(707) 585-1991
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 60		CENSUS: 27	DATE:	05/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Jesse Carbone-Administrator/Program Manager		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alviso, conducted a Required -1 Year visit, on 5/15/2025 at approximately 9:45am, and met with Administrator/Program Manager,Jesse Carbone. Day program has a fire clearance for sixty(60) capacity, which includes seven(7) non-ambulatory. During today's inspection the facility was operating with twenty-three (23) clients on-site, and four (4) clients in the community. Hot water was measured at 107.6 degrees Fahrenheit. Facility has a working carbon monoxide detector. Facility has five (5) fire extinguishers that are showing charged; Administrator stated they will follow-up with the appointment to re-service and re-tag all fire extinguishers. All exits were free and clear of obstruction. Facility's large mounted first aid kit had a large supply of all required items. Facility has an AED machine mounted in it's storage case by the first aid case. Facility had a sufficient supply of soap, cleaners/disinfectants, paper supplies, and personal protective equipment (PPE). Facility had a large cabinet that contained extra clothes in case a client needs a change of clothing. The facility has sufficient furnishings for participants use. Facility has a refrigerator accessible to clients in care, for their lunches, snacks, and drinks. There are some vending machines for participant use as well. There is a kitchen area that is supervised by staff when in use, and staff supervise clients so they don't have access to the kitchen's stove. There are many activity items available to participants of the day program. The outside front of the day program has a place for clients to sit at and it is shaded in the afternoons. Continued on LIC809C..

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SERVICES	FACILITY NUMBER: 496801598
	VISIT DATE: 05/15/2025

NARRATIVE

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The back area of the program site has a vegetable garden and two picnic tables for clients use; The picnic tables do have umbrellas that will put on so clients will also have shade. Facility has a large area, two large rooms that provide separate classes, activities, and areas for lunch/snack times. There is a large room for movies and activities, and a room that is a quieter area with stored activities, table, seating, with a fish tank, and there's an office room for staff. All clients have a locker and the key is in the clients possession.

The facility has a required infection control plan. The facility has a required emergency disaster plan. Last emergency disaster drills were conducted 4/22/25 a fire drill, and 4/1/25 an earthquake drill.

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

Licensee to submit the following updated annual forms by 5/15/25:
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Emergency Disaster Plan-updated & reviewed as needed. submit copy if changes, submit last page signed and dated if no changes.
LIC400-Affidavit Regarding Client Cash Resources
LIC402-Surety Bond (if handling client cash)
Infection Control Plan- updated & reviewed as needed- submit copy if changes, submit last page signed and dated if no changes.

LPA discussed the required administrator change documentation needed for requesting a change of the Administrator; LPA sent an email with all needed documentation to Jesse Carbone, Program Manager.

There were no deficiencies cited today.
Exit interview conducted with the Administrator/Program Manager Jesse Carbone.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC809 (FAS) - (06/04)

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