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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804140
Report Date: 11/21/2023
Date Signed: 11/21/2023 10:46:30 AM

Document Has Been Signed on 11/21/2023 10:46 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:
11/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 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 re-inspecting the facility due to a Pre-licensing inspection visit dated for May 22, 2023 where the LPA issued a LIC 9102-Technical Advisory regarding old furniture in prospective client rooms. LPA was greeted at the door by Administrator/Licensee, Domonique Thomas. The Fire Clearance was granted for 6 Ambulatory clients. In addition, LPA observed an Recreational Vehicle (RV) on premises that will house the staff members (See LIC 812-CAB 6.0 Fire Clearance granted dated for November 9, 2023). This RV was also approved by the City of Santa Rosa on November 6, 2023 on a basis for Temporary Use. This Temporary Use permit (APN: 182-170-027, Zone: R-1-6) will expire five years from the date of issuance.

LPA and Administrator/Licensee toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. LPA observed new furniture in prospective client rooms that are ready for client placement which consists of a bed, night stands and closet space to store clothing. 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 retested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature was reinspected and 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. LPA was shown the Emergency Generator which was located in the backyard of the facility.

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: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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