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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804085
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:39:44 AM

Document Has Been Signed on 09/01/2022 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:ADULT DAY RESPITE PROGRAM, SANTA ROSAFACILITY NUMBER:
496804085
ADMINISTRATOR:LARKIN, JAKEFACILITY TYPE:
775
ADDRESS:490 MENDOCINO AVE STE 105TELEPHONE:
(707) 525-0143
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 15CENSUS: 0DATE:
09/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director of Social Services - Council on Aging - Renee Tolliver & Property Manager Debbie Ahern-ColgroveTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Hansen conducted an announced pre-licensing inspection and was welcome by Property Manager Debbie Ahern-Colgrove, Director of Social Services for Council on Aging Renee Tolliver arrived shortly after. Fire clearance has been approved by Santa Rosa Fire Department for 15 non-ambulatory clients. Facility has no waiver requests at this time. Component III orientation has been waived by the RO. Facility will operate 5 days per week between 9:30am to 3:30pm.

LPA toured facility and observed: Facility is a two-floor building with 12 office spaces. This office space on the first floor contains one bathroom that all clients will use. The facility will have a phone designated for client use. Personnel records and client records will be stored in the facility office area.

During today’s visit LPA observed the following items:

All exits were unobstructed
Four hardwired smoke detectors
Fire Extinguisher charged and serviced July 27, 2022
The water temperature was tested during inspection and was not within regulation of 105 – 120 Degrees F.

Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ADULT DAY RESPITE PROGRAM, SANTA ROSA
FACILITY NUMBER: 496804085
VISIT DATE: 09/01/2022
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Pre-licensing is incomplete with corrections needed.

The following corrections are needed to proceed with the application process:

Required postings: CCLD complaint poster (PUB 475) in the required size 20” x 26”, and Theft & Loss
Program Posted.
COVID-19 postings and screening station
Lockable separate cabinets for medications, toxins/cleaners, and knives.
Missing tiles in celling need replacing.
Carbon monoxide detector.
Complete first Aid kit, night-lights, and flashlights for emergency lighting.
The water temperature needs to be within regulations of 105 – 120 Degrees F.


A subsequent announced visit will be conducted to complete the inspection tool, Component III orientation has been waived. CAB unit will be notified when visit is complete.


No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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