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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801932
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:19:44 PM

Document Has Been Signed on 11/30/2023 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DUNGARVIN CALIFORNIA LLCFACILITY NUMBER:
496801932
ADMINISTRATOR:FAIRCHILD, CARRIEFACILITY TYPE:
775
ADDRESS:433-439 BEAVER STTELEPHONE:
(707) 543-5895
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 75CENSUS: 38DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Carrie FairchildTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Carrie Fairchild.

LPA initiated a tour of the buildings and grounds at approximately 9:20am and made the following observations: Facility consists of four suites with one suite being used for Administrative offices and three designated for participants. Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in bathrooms used by participants measured at 108, 115 and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Cabinets containing cleaning supplies were locked. Clients bring their own lunch and those who stay at the facility during the day eat in common areas. Refrigerators for client lunches appeared clean.

Fire extinguishers were last inspected August, 2023. Facility has a centralized smoke alarm system that is maintained by a vendor. Most recent service was conducted January, 2023. Most recent fire/disaster drill was conducted November, 2023. The most recent inspection of facility vehicles was conducted by a vendor in October 2023.

Five staff and five participant files were reviewed. Staff have required First Aid and CPR Certificates. Facility does not currently store or assist any client with self administration of regularly scheduled medication but Administrator did explain the medication procedures to LPA.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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