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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496804085
Report Date:
10/01/2024
Date Signed:
10/01/2024 12:26:56 PM
Document Has Been Signed on
10/01/2024 12:26 PM
- 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 ROSA
FACILITY NUMBER:
496804085
ADMINISTRATOR/
DIRECTOR:
STEPHANIE THUESON
FACILITY TYPE:
775
ADDRESS:
490 MENDOCINO AVE STE 105
TELEPHONE:
(707) 525-0143
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95401
CAPACITY:
15
CENSUS:
11
DATE:
10/01/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:
Jeanett "Jet" Howell & Justine Alves (Coordinator & Site Assistant)
TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting an Annual Required inspection and met with Jet Howell Site Coordinator. Annual fees are current and contact information was reviewed. The Day program operates Tuesday & Thursday 9am- 3pm.
LPA/staff initiated a tour of the facility at 10:30 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Participants were observed at Day Program engaged in activities. The activity schedule for the day was written on a white board. The day program operates out of a primary room within the 490 Mendocino Ave. Meals are provided by Meals on Wheels and contracts with the facility to serve participants. Participants have the choice to bring their lunch. Program maintains a supply of coffee for snacks. There is one bathroom available for participant use. Bathrooms were equipped with grab bars to ensure safety. Toxins were inaccessible. Facility does not handle cash and medications. The facility does not provide transportation. The smoke alarm system is maintained by the building manager in 8/20/24. Most recent Disaster drill was conducted 10/1/24. Carbon monoxide was tested and operational. Water temperature in bathroom measured at 118.9 degrees F which is within allowable range of 105-120 degrees F. Fire extinguisher was charged and serviced as of November 2023.
LPA initiated file review at 11:00am. Two staff files and five participant files were reviewed. Staff have required First Aid/CPR certificates and eight hours of annual training required hours. All participants have current care plans and medical assessments on file.
Facility provided updates of the following: Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500). No deficiencies cited during today's inspection. Exit interview conducted with Site Coordinator & copy of report was given.
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Marisol Cuadra
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/01/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/01/2024
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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