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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804085
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:00:31 AM

Document Has Been Signed on 11/01/2022 11:00 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:
11/01/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Renee Tollivar (Director of Social Services for Council on Aging)TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a Pre-licensing Continuation Facility Inspection and met with Renee Tollivar, Director of Social Services for Council on Aging. A Pre-Licensing inspection was completed on 9/1/2022. The facility has a fire clearance approval from Santa Rosa Fire Department for a total capacity of 15 non-ambulatory participants. Day Program will operate 5 days per week between 9:30am to 4:30pm and Licensee will ensure sufficient staffing at all times. The facility has a screening station with hand sanitizer, masks and thermometer.

The following items were reviewed during this pre-licensing inspection:
· Locked cabinet for medications, toxins and sharps.
· Tiles in ceiling needing repair.
· Carbon monoxide were inspected and working properly.
· Water temperature was within regulation.
· Complete first aid kit including flashlights.
· Required postings: CCLD complaint poster and Covid19 related posters.

Pre-licensing passed; Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation.

LPA will notify CAU of today's Pre-licensing inspection.

No deficiencies cited at today’s inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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