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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804140
Report Date: 05/22/2023
Date Signed: 05/22/2023 10:52:10 AM

Document Has Been Signed on 05/22/2023 10:52 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:FREMONT HOUSEFACILITY NUMBER:
496804140
ADMINISTRATOR:THOMAS, DOMONIQUEFACILITY TYPE:
735
ADDRESS:2120 FREMONT DRTELEPHONE:
(707) 542-1595
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 0DATE:
05/22/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator/Licensee, Domonique ThomasTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Fremont House for the purpose of conducting a Pre-Licensing inspection. LPA was greeted at the door by Administrator/Licensee, Domonique Thomas. The Fire Clearance was granted for 6 Ambulatory clients with 0 Non-Ambulatory and 0 Bedridden clients. Administrators Certificate (Administrator Certificate #: 6063899735 was issued on 11/07/2022 with an expiration 07/11/2024) was reviewed by the LPA during the Pre-Licensing Inspection and found to be valid and appropriate.

LPA and Administrator/Licensee toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. However, during the Pre-Licensing inspection, LPA observed 1 room that is ready for a client to reside in. The remainder of the rooms still have old furnishings present (LIC 9102-Technical Advisory). Fire Extinguishers was most recently purchased and observed to be brand new during the Pre-Licensing inspection. All smoke detectors and a carbon monoxide detector were tested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature measured at 118 degrees in 1 of 1 clients bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Client records, personnel Records, medication will be locked and in separate cabinets, toxins are kept locked and inaccessible to clients in care. Firearms were locked and stored per regulations. Facility has a first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is an outdoor space for activities with a shaded area. Facility had sufficient perishable and non-perishable foods. Food menu was observed during the Pre-Licensing Inspection. During the Pre-Licensing inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Emergency Disaster plan was discussed with the Administrator. All staff will be trained in the Emergency Disaster and PPE training. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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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: FREMONT HOUSE
FACILITY NUMBER: 496804140
VISIT DATE: 05/22/2023
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LPA was shown the Emergency Generator that was located in the backyard of the facility.

Component III was discussed in detail with the Administrator/Licensee.

Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
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