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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890075
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:47:56 PM

Document Has Been Signed on 09/29/2022 03:47 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: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:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Director of Services James Cox TIME COMPLETED:
03:50 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control Inspection of the facility and met with James Cox, Director of Services (DOS). The program is open Monday through Friday from 8:00am to 3:30pm. Facility provides daily outings into the community as well as site-based activities.

There are currently 35 participants on a daily basis at the facility with 65 participants out in the community. At 2:35 PM LPA conducted inspection and toured the facility and grounds with James Cox, DOS. Required documents are posted throughout the facility. Facility has a centralized sign-in sheet that documents staff and participants attendance. Bathrooms used by participants were sanitary and in good repair. Smoke; fire extinguisher are tested annually, carbon monoxide inspected regularly by Fire Department. The facility's fire extinguishers were last serviced May 26, 2022. Program shares building with other organizations. In the central office area with cubicles for staff are where medications are centrally stored in a locked cabinet, although at this time there are no participants who take medications while at the facility. 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. Large program production space with two shared bathrooms, restrooms have stalls, sink, soap dispensers. Water in bathrooms measured within allowable range. Facility has personal lockers for participants to store their personal items. Participants bring sack lunches/snacks and there is a refrigerator available for them. 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.

LPA reviewed Licensing Information System (LIS) with Director of Services who informed all information is up to date. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 2
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: 09/29/2022
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LPA was presented with proof of CPR & 1st Aid certification for staff.

No deficiencies cited during today's inspection.

LPA Hansen is requesting Director of Services to update and submit the following documents by 10/15/2022 to LPA Cuadra or SRRO:




LIC308 Designation of Responsibility
LIC500 Personnel Report
LIC 610E Emergency Disaster Plan
Control of Property – New Lease
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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