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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890048
Report Date: 02/13/2023
Date Signed: 02/13/2023 02:17:00 PM

Document Has Been Signed on 02/13/2023 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: 8DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jake Larkin, Day Respite Program ManagerTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced on 3/13/2023 at approximately 12:50 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 8 attendees. 8 out of 8 clients are vaccinated and boosted, 8 out of 8 staff are vaccinated and boosted. Clients and staff are screened and signed in at the start of the program. Staff were observed wearing masks.

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

LPA Requested the following documents be submitted to SRRO by 2/27/2023.

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



No deficiencies cited during today's inspection. Exit interview conducted with Jake Larkin.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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