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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890048
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:29:32 PM

Document Has Been Signed on 04/29/2024 03:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SANTA ROSA SENIOR SOCIAL CLUBFACILITY NUMBER:
496890048
ADMINISTRATOR/
DIRECTOR:
SHIRRYL BAYLESSFACILITY TYPE:
775
ADDRESS:2500 PATIO COURTTELEPHONE:
(707) 525-0143
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 15CENSUS: 6DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Administrator, Shirryl BaylessTIME VISIT/
INSPECTION COMPLETED:
03:44 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required annual visit and met with Program Coordinator Shirryl Bayless. The program currently is leasing 2 rooms within a church and is open on Mondays & Wednesdays from 10:00am to 2:00pm. There are currently 7 clients enrolled in the program and 6 were present at the time of the visit.

LPA toured the facility at 1:00pm which was found to be clean, in good repair, and a comfortable temperature. In addition to the class room, Program also has access to a kitchen, a gymnasium, and a video screening room in which they enjoy music or movies. There are two [2] bathrooms for participants to use, one for men and one for women. Hot water measured at 128 degrees F, which falls outside of the allowable range of 105 to 120 degrees F. However, Program Coordinator will contact landlord to turn down hot water heater and will monitor all hand washing to make sure participants are safe.

Lunches are provided by Meals on Wheels which are delivered daily in insulated food transportation carriers for both hot and cold food items. No toxins or other items that could constitute a danger were observed. Program does not handle client medications and does not provide transportation. No hazards were observed in the indoor activity areas, including the gymnasium and video screening room.

Fire extinguishers are current as of 9/12/2023. Smoke detectors are hard wired and are on an annual inspection schedule. Facility is in a commercial building and inspections are responsibility of landlord. Carbon monoxide detector was present in the classroom itself. LPA tested carbon monoxide detector and found it working at the time of the visit. First Aid kit present and all required items present. AED present.

At approximately 1:45pm LPA reviewed seven [7] client files and two [2] staff records. All required documentation present.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SANTA ROSA SENIOR SOCIAL CLUB
FACILITY NUMBER: 496890048
VISIT DATE: 04/29/2024
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Continued from 809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Current Lease

No deficiencies cited during this inspection. Exit interview conducted with Administrator/Program Coordinator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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