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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804187
Report Date: 02/27/2024
Date Signed: 02/27/2024 01:16:11 PM

Document Has Been Signed on 02/27/2024 01:16 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:COTTONWOOD COMMUNITY SUPPORT HOMEFACILITY NUMBER:
496804187
ADMINISTRATOR:HAYES, TESS R.FACILITY TYPE:
735
ADDRESS:411 COTTONWOOD DR.TELEPHONE:
(707) 623-8025
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Tess Hayes (Licensee)TIME COMPLETED:
01:31 PM
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Licensing Program Analyst, (LPA) Cuadra arrived unannounced to conduct a Pre-licensing inspection and met with Licensee/Applicant Tess Hayes.

LPA/Licensee initiated a tour of the inside and outside of the facility at 12:00 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Facility received an approved fire clearance from the local fire department 9/5/2023 for four ambulatory clients. No major construction has been performed in the facility. Facility is a one story residence with four single resident bedrooms that were furnished per regulation. Water temperature in client bathroom measured at 106.2 degrees F which is within allowable range of 105 to 120 degrees F. Facility has enough dishes including pots and pans for client and staff use. Enough linens to accommodate clients were available. Cabinets designated for cleaning supplies and other items that could pose a risk had locks. A locked closet is designated for medication and files. Facility has a first aid kit along with flashlights throughout facility. Fire extinguisher is charged and serviced as September 2023. Carbon monoxide detector was tested and operational. Last disaster drill was conducted on November 1, 2023. Administrator Certificate for Tess Hayes 6037085735 expires August, 19 2025. Licensee/Applicant discussed that all clients files would need to be updated upon license. LPA observed required postings including the CCL Complaint Poster, Resident's Rights, menu and activity calendar. LPA confirmed that Applicant signed up for the Guardian and Provider Information Notices (PINs) that the Department sends out. A Component III was completed with Applicant.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license and no deficiencies cited at today’s inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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