<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803113
Report Date: 07/31/2024
Date Signed: 07/31/2024 12:41:57 PM

Document Has Been Signed on 07/31/2024 12:41 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 - ROHNERT PARKFACILITY NUMBER:
496803113
ADMINISTRATOR/
DIRECTOR:		DAVIS, SHANNONFACILITY TYPE:
775
ADDRESS:125 SOUTHWEST BLVDTELEPHONE:
(707) 664-8000
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 45CENSUS: 30DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Shannon Davis-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 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 Analysts (LPAs), Alviso and Loera ,conducted a Required- 1 Year visit, on 7/31/24 at approximately 8:30am, and met with Administrator Shannon Davis.

There are thirty-six (36) clients that are enrolled in day program.Today there are thirty (30) clients in attendance, and a total of twenty-seven (27) are out in the community today.

There are sixteen (16) staff working at the day program, and thirteen (13) of the staff are in the community with the clients.

Day program has a fire clearance for forty-five(45)) capacity, of which twenty (20) may be non-ambulatory. The facility has a required infection control plan. The facility has a required emergency disaster plan. There is a first aid kit with emergency supplies. Fire drills are held monthly, including evacuation of the building. Per record review, Last fire/emergency drills were held on 6/24/24 and 7/23/24.

The LPAs reviewed six (6) client files.

The LPAs reviewed six (6) staff files. Per record reviews, all staff had criminal record clearance as required; All staff had first aid and CPR certification. LPAs reviewed staff training.

LPAs toured the facility with the Administrator. All exits were unobstructed. All fire extinguishers were serviced and tagged. Hot water was checked at 112.4 degrees Fahrenheit, which is within regulation. Facility was clean and orderly. Sufficient supply of personal protective equipment (PPE).

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: DUNGARVIN CALIFORNIA - ROHNERT PARK
FACILITY NUMBER: 496803113
VISIT DATE: 07/31/2024
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
26
27
28
29
30
31
32
 There was a sufficient supply of cleaners/disinfectants, paper products, and furnishings for client use. Cleaners/disinfectants were locked up and inaccessible to clients in care. Medications were locked up and inaccessible to clients in care. The private courtyard was clean and orderly, and had outside patio furnishings for client use.

LPA is requesting the following documents to be submitted by 8/31/24.
LIC500 Personnel Report
LIC308 Designation of Responsibility
LIC610 Emergency Disaster Plan-updated as needed
Infection Control Plan-Updated as needed
LIC400 Handling of Client Cash Resources- must be completed (include copy of surety bond if handling cash)

No deficiencies cited during today's visit.
Exit interview conducted with Administrator Shannon Davis.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2