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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801995
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:26:46 PM

Document Has Been Signed on 04/25/2022 03:26 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:MY FATHER'S GARDEN ADULT RESIDENTIAL CARE FACFACILITY NUMBER:
496801995
ADMINISTRATOR:JOHNSON, CANZADIEFACILITY TYPE:
735
ADDRESS:475 WINDSOR RIVER ROADTELEPHONE:
(707) 836-1124
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Licensee/Administrator, Canzadie JohnsonTIME COMPLETED:
03:36 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Canzadie Johnson. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed a screening station near the entrance. Licensee confirmed they screen visitors but indicated that most individuals visit in multiple outside areas of the facility. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per day and after use.

Staff continue to receive Covid-19 training and have been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, N95s, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced March 2021. Hardwired smoke and carbon monoxide detectors throughout facility were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MY FATHER'S GARDEN ADULT RESIDENTIAL CARE FAC
FACILITY NUMBER: 496801995
VISIT DATE: 04/25/2022
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Continued from LIC809C

Licensee and LPA discussed their Emergency Disaster Plan and the Infection Control Plan due to CCL no later than June 30, 2022.

Licensee/Administrator to submit updates of the following documents by 5/25/2022:
  • LIC 308 Designated Administrator
  • LIC 500 Personnel Summary
  • LIC 400 Affidavit Regarding Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610 Emergency Disaster Plan
  • LIC 9020 Register of Facility Client’s/Resident’s
  • Copy of Property Tax document showing you have control of property.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
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