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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804085
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:58:08 AM

Document Has Been Signed on 01/20/2023 11:58 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:
01/20/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jake Larkin (Administrator)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cuadrai arrived unannounced for the purpose of conducting a Post-Licensing inspection. LPA was greeted by Administrator, Jake Larkin. The Day Program does not have any participants and will operate Tuesdays and Thursdays from 10am to 2pm starting on February 14, 2023.

A Pre-Licensing inspection was completed on 11/1/2022. The facility has a fire clearance approval from Santa Rosa Fire Department for a total capacity of 15 non-ambulatory participants. 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 post-licensing inspection:
· Locked cabinet for medications, toxins and sharps.
· 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.
· Meals are provided pre-packaged meals by Meals on Wheels.
· The Day Program does not provide transportation.
· Fire extinguisher charged and serviced as of July 2022.

No deficiencies cited at today’s inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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