<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890075
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:26:16 PM

Document Has Been Signed on 09/02/2021 04:26 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BECOMING INDEPENDENTFACILITY NUMBER:
496890075
ADMINISTRATOR:JAMES COXFACILITY TYPE:
775
ADDRESS:1745 COPPERHILL PARKWAYTELEPHONE:
(707) 524-6670
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 100CENSUS: 0DATE:
09/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:James Cox (Administrator)TIME COMPLETED:
04:37 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Pre-Licensing inspection for a change of location and capacity decrease, LPA met with Applicant, James Cox and Paula Finley. LPA conducted Risk assessment with Applicant. LPA confirmed that applicant reviewed PIN 21-36-ASC.

LPA/Applicant initiated a tour of the facility and made the following observations: Day Program is located in a large building that consists of a reception area were staff, participants and visitors are screened for Covid19 symptoms, conference room area with large glass window will be used also when participants need quite time, central office area with cubicles for staff where medications will be centrally stored in a cabinet, large program production space with two shared bathrooms where participants are going to be accompanied by staff when they need to use restroom, restrooms have stalls ,sink, soap dispensers, a small program space, warehouse has a kitchen with functioning appliances. Facility has personal lockers for participants to store their personal items, participants will bring their own snacks and lunches. There is a refrigerator available for them. Facility doesn't handle cash resources. Participants will be involved with community based activities.

Facility has an approved fire clearance dated 9/1/21 for 100 ambulatory where 15 could be non-ambulatory participants. The facility's fire extinguishers were last serviced August 2021. Water in bathrooms measured within allowable range. LPA observed three first aid kits through the facility. Toxins will be stored in a locked closet in the kitchen. There are locks on multiple cabinets and drawers in the kitchen where items will be stored that may pose a risk to health and safety. Facility has a contract with R&D transportation services, Applicant provided a copy of vendor transportation mitigation re-entry plan related to Covid19 and approved by NBRC. Applicant submitted their Covid19 Mitigation Plan and it will be reviewed. Participants and staff records are kept electronically and applicant associated staff to this facility. Required documents are posted thru out the facility: Covid19 related posters, personal rights, facility sketch, disaster plan and activity board. Outdoor entrance include ramp for safety purposes. Based on knowledge of Applicant the Component III is waived. Application is being handled by Regional Office and facility will be considered for licensure.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1