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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804187
Report Date: 01/24/2025
Date Signed: 01/24/2025 02:19:58 PM

Document Has Been Signed on 01/24/2025 02:19 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/
DIRECTOR:
HAYES, TESS R.FACILITY TYPE:
735
ADDRESS:411 COTTONWOOD DR.TELEPHONE:
(707) 623-8025
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 3DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Tess Hayes (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analysts (LPAs) Cuadra and Magdaleno arrived unannounced to conduct an Annual Required inspection and met with Licensee Tess Hayes. Clients were attending Day Program.

LPAs/Licensee initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 108.5 and 109.2 degrees which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet. Medications are centrally stored in locked cabinet and medication records were reviewed. Fire extinguisher was last inspected January 2025. Smoke detectors and carbon monoxide detector were tested and operational. Most recent Fire/Disaster drill was conducted 9/20/24. Facility does have a current activity calendar and menu. Cash resources and documentation were reviewed. Required postings were observed.

At 1:00pm LPA conducted a file review of three client and two staff files. All clients' records have updated care plans on file. All staff have current CPR/1st aid certificates and staff does have required annual training hours on file. Administrator Certificate for Tess Hayes expires 8/19/2025.

Administrator agreed to submit updates of the following documents by 1/31/2025: LIC500 Personnel Report, LIC308 Designation of facility responsibility, Surety bond and LIC400 cash affidavit for clients.

No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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