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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890075
Report Date: 03/18/2022
Date Signed: 03/18/2022 11:24:36 AM

Document Has Been Signed on 03/18/2022 11:24 AM - 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:BECOMING INDEPENDENTFACILITY NUMBER:
496890075
ADMINISTRATOR:JAMES COXFACILITY TYPE:
775
ADDRESS:1745 COPPERHILL PARKWAYTELEPHONE:
(707) 524-6670
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 100CENSUS: 100DATE:
03/18/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:James Cox (Executive Director)TIME COMPLETED:
11:40 AM
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 Post-License inspection and met with Executive Director, James Cox. The program will be open Monday through Friday from 8:00am to 3:30pm. Facility provides daily outing into the community as well as site based activities. LPA conducted risk assessment with staff at the facility. LPA/Executive Director reviewed PIN 22-05, 22-06, 22-07 & 22-09.

LPA toured the facility and grounds. 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. Bathrooms used by participants were sanitary and in good repair. Smoke; fire extinguisher are tested annually, carbon monoxide inspected regularly by Fire Department. Program shares building with other organizations. 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 is used also when participants need quite time, central office area with cubicles for staff where medications are centrally stored in a cabinet, large program production space with two shared bathrooms, restrooms have stalls ,sink, soap dispensers. Facility was a comfortable temperature and passageways were free from obstructions. There is a program space used for production activities for 5 participants, warehouse has a kitchen with functioning appliances. Facility has personal lockers for participants to store their personal items, Participants bring sack lunches/snacks and there is a refrigerator available for them. There are locks on multiple cabinets and drawers in the kitchen where items that could pose a risk are to be stored for the participant's safety. Participants and staff records are kept electronically. Staff have CPR and 1st Aid certifications. Day Program documents vaccination status, staff are fully vaccinated, boosted except two staff that have exemptions on file and they undergo weekly surveillance testing. Most recent Emergency Disaster Drill was conducted on 2/24/22. The facility's fire extinguishers were last serviced June 2021. Water in bathrooms measured within allowable range. LPA observed 3 first aid kits through the facility. Facility doesn't handle cash resources. Facility has a contract with R&D transportation services who daily screen participants at entry and documents the results. Facility submitted their Covid19 Mitigation Plan and approved on 9/10/21. Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BECOMING INDEPENDENT
FACILITY NUMBER: 496890075
VISIT DATE: 03/18/2022
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
26
27
28
29
30
31
32
Continued from LIC809...

During today's visit LPA is following up on an incident along with a SOC341 received on 2/25/22 from the facility reporting that on 2/24/22 participant (P1) came to day program and staff noticed visible bruises on their upper right arm and left eye. P1 sustained two bruises on their left .upper arm, one closer to their shoulder and one closer to their elbow that appeared to be one inch in diameter, the bruise on left eye is near the outer socket area and appeared to be half inch in diameter. Staff checked on P1 about the bruises when asked about the bruises P1 said "mom and brother" while pointing to the bruises on their arms. When staff asked about their eye, P1 replied "I hit the table". P1 speaks spanish primarily and the staff was not able to gather any further details. Staff immediately checked in with their management team to share information about P1's bruises. The team management gathered information and proceeded to report the incident to Adult Protective Services (APS) who instructed them to file a SOC341 to be submitted to CCL and law enforcement. Facility supervisor spoke with Officer Perry from Petaluma Police Department who conducted an investigation at P1's home. P1 continued to participate in their regular day as scheduled and did not express feeling unsafe or hesitant to return home. LPA was informed that there had been 4 similar reports on file to the police and previous reports were unsubstantiated.

No deficiencies cited during today's inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3