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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803583
Report Date: 11/07/2023
Date Signed: 11/07/2023 11:48:15 AM

Document Has Been Signed on 11/07/2023 11:48 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:ALCHEMIAFACILITY NUMBER:
496803583
ADMINISTRATOR:LIZ JAHRENFACILITY TYPE:
775
ADDRESS:394 TESCONI COURTTELEPHONE:
(707) 978-3229
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 45CENSUS: 37DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Mary Gannon Graham (Artist Coordinator)TIME COMPLETED:
12:03 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Mary Gannon Graham (Artist Coordinator). The program is open Monday through Friday from 9:00am to 3:00pm. Required postings were observed. Facility does not provide transportation.

LPA initiated a tour of the facility at 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Participants were participating in various activities in classrooms with Artist Mentors. Facility was compliant with the ratio dictated by the regional center. Participants bring their own lunches which are stored in lockers. LPA observed multiple completed art projects throughout facility. Bathrooms had hand rails for safety and appeared sanitary. Water temperature read at 105.1 F which are within regulation of 105 and 120 degrees Fahrenheit. Toxins were inspected and are stored in a locked closet located in the staff room that was also locked at time of inspection. Fire extinguishers were last serviced August, 2023. Facility has a centralized smoke detector system that is maintained by a vendor and inspected by the local fire department. Most recent service was conducted August 2023. Last Emergency Disaster Drill was conducted on 10/19/23.

LPA initiated at 9:30am file review of five staff and ten participant files. Staff files reviewed have required First Aid, CPR Certificates. However, four out of five staff did not have at least 8 hours of training documented on file a technical violation was issued. Facility does not handle medications or cash resources. Participant files have needs and services plans updated, but 9 out of 10 participants (P1-P9) medical assessments were not on file. Facility showed a letter dated 8/31/23 sent to participant's responsible party requesting an updated physician's report (LIC602) form.

Facility will provide updated copies of the following documents by 11/30/23: Designation of Responsibility (LIC308), Personnel Report (LIC500) and lease agreement. No deficiencies were cited during this inspection. Exit interview was conducted with Artist Coordinator. A copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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Document Has Been Signed on 11/07/2023 11:48 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/07/2023 at 11:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ALCHEMIA
FACILITY NUMBER: 496803583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Artist Coordinator's observation, interview and record review, the licensee did not comply with the section cited above in 9 out of 10 participant's medical assessments were not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Facility agreed to obtain current medical assessments for all participants and facility will submit a self-certification LIC9098 form to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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