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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803966
Report Date: 04/26/2021
Date Signed: 04/28/2021 11:10:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WOODWARD ASSISTED LIVINGFACILITY NUMBER:
496803966
ADMINISTRATOR:AMADOR, ADAFACILITY TYPE:
740
ADDRESS:1825 WOODWARD DR.TELEPHONE:
(530) 308-6230
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: DATE:
04/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Applicant, Steven BowdenTIME COMPLETED:
10:30 AM
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Licensing Program Analysts Willis and Gonzalez-Campos met with Applicant, Steven Bowden and Administror, Ada "Jackie" Amador virtually to conduct a Pre-Licensing Inspection. Parties met remotely to observe Covid-19 precautions.

LPAs and Applicant toured the inside of the facility and grounds via video conference. Facility is a one-story residence with four bedrooms, three bathrooms, a living room and a kitchen. Two bedrooms are designated as single occupancy and two are designated for double occupancy. Facility bedrooms have all personal accommodations. Residents bedrooms had the required furnishings, such as a dresser, night stand, lamp and bed linens. Bathrooms showers have a non-skid shower floor and grab bars for safety. Facility received an approved fire clearance dated March 8, 2021 that allows for six non-ambulatory residents. LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). COVID-19 required postings were not observed and will be provided to Applicant. Applicant showed what contents are in their First Aid Kit.. Applicant tested the water temperature at 111.8 degrees F which is within regulation of 105 & 120 degrees F.

Facility will lock centrally stored medications in a cabinet in the kitchen. LPA observed that cleaning supplies and toxins are locked in a cabinet under the kitchen sink and in a locked cabinet in the laundry room. Perishable and non-perishable foods observed per regulation. Facility has space indoors and outdoors for resident activities.

Component III was completed with Applicant and Administrator. Once pictures of Covid-19 posters are received, LPA will notify Application Unit so application process may proceed.

No deficiencies cited at today’s inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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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