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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801995
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:25:15 PM

Document Has Been Signed on 04/20/2023 03:25 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: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:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator, Canzadie JohnsonTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Canzadie Johnson.

LPA initiated a tour of the facility around 1:00pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathrooms measured at 120 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked.

Fire extinguisher were last inspected April 2023. Combination Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted April 18, 2023.

Four staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Licensee/Administrator Johnson Canzadie L 6023132735 expired 12/10/2022 and is on the Department's pending list . Medications and medication records were reviewed. Client P&I was also reviewed.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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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: MY FATHER'S GARDEN ADULT RESIDENTIAL CARE FAC
FACILITY NUMBER: 496801995
VISIT DATE: 04/20/2023
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 5/20/2023:


LIC 500 Personnel Summary
LIC508 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

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

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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