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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801995
Report Date: 05/13/2024
Date Signed: 05/13/2024 10:39:55 AM

Document Has Been Signed on 05/13/2024 10:39 AM - 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/
DIRECTOR:
JOHNSON, CANZADIEFACILITY TYPE:
735
ADDRESS:475 WINDSOR RIVER ROADTELEPHONE:
(707) 836-1124
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 4DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Licensee/Administrator, Canzadie JohnsonTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Canzadie Johnson.

LPA initiated a tour of the facility at approximately 8:30 am 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 within regulations of 105 to 120 degrees F. 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 5/1/2024. Combination Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted April 16, 2024.

Three staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Licensee/Administrator Canzadie Johnson # 6023132735 expired 12/10/2024. Medications and medication records were reviewed. Client P&I were documented, secure and not commingled.
Licensee/Administrator to submit updates of the following documents by 5/30/2023:
LIC 500 Personnel Summary
LIC 508 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Control of Property (Deed)

No deficiencies cited during this inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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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