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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890048
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:17:34 PM

Document Has Been Signed on 03/16/2022 02:17 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:SANTA ROSA SENIOR SOCIAL CLUBFACILITY NUMBER:
496890048
ADMINISTRATOR:BALDARAMOS, DEBBIEFACILITY TYPE:
775
ADDRESS:2500 PATIO COURTTELEPHONE:
(707) 525-0143
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 15CENSUS: 11DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Day Respite Program Manager, Jake LarkinTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 3/16/2022 at approximately 1:30 PM to conduct a Required - 1 Year inspection. LPA met with Day Respite Program Manager, Jake Larkin. This inspection was focused on the infection control practices and procedures of this day program.

Day program reopened on 2/23/2022 and is open on Mondays/Wednesdays from 10AM-2PM. There are currently 11 attendees. 10 out of 11 clients are vaccinated and boosted, 4 out of 4 staff are vaccinated and boosted. Unvaccinated attendee provides negative test before start of program. Clients and staff are screened and signed in at the start of the program. Clients and staff were observed wearing masks.

LPA observed available surgical masks and hand sanitizer. Program has an available first aid kit. LPA requested CPR/First Aid certificates during inspection. A sprinkler system was observed, as well as a carbon monoxide detector. Program has submitted a mitigation plan to Community Care Licensing.

LPA Requested the following documents during the visit:

LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan.

LPA and Program Manager discussed associating all Council of Aging staff to all day program sites. Licensee to submit LIC 9182, LIC 508 and ID to CCL for association.

No deficiencies cited during today's inspection. Exit interview conducted with Jake Larkin.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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