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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890075
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:04:07 PM

Document Has Been Signed on 09/10/2024 03:04 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/
DIRECTOR:		JAMES COXFACILITY TYPE:
775
ADDRESS:1745 COPPERHILL PARKWAYTELEPHONE:
(707) 524-6670
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 100CENSUS: 42DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Service Director, Stephanie Rodriguez and Sarah Unciano Lund, SupervisorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA) Hansen arrived unannounced to conduct an Annual Required inspection and met with Sarah Unciano Lund (Supervisor). Currently the facility is operating Monday-Friday between 8:00am to 2:30pm. Facility provides daily outings into the community as well as site-based activities.

At 8:45 am LPA/Supervisor conducted inspection and toured the facility and grounds. Required postings were observed. Facility has a centralized sign-in sheet that documents staff and participants attendance. Bathrooms used by participants were sanitary and in good repair. Smoke and carbon monoxide along with sprinkler system inspected regularly by Fire Department. The facility's fire extinguishers were last serviced August 25, 2024. Facility was a comfortable temperature and passageways were free from obstructions. Water in bathrooms measured within allowable range. Facility has personal lockers for participants to store their personal items. Participants bring lunches/snacks and there is a refrigerator available for them. Facility doesn't handle cash resources. Facility van was inspected and contained a first aid kit and fire extinguisher was charged and serviced. First aid kit was fully stocked. Last disaster drill was conducted on June 20, 2024. Medication and medication records were reviewed.

At 9:45am LPA initiated file review of five participants and five staff. Staff have required First Aid and CPR training. Participant's files have current medical assessment and appraisals/needs and services plans.

LPA obtained while at facility: Addendum/updated Lease & Emergency Disaster plan signed & dated and Designation of Responsibility (LIC308).

Facility will provide updated copies of the following documents by 9/22/24: Personnel Report (LIC500).



Exit interview was conducted with Service Director Stephanie Rodriguez and Sarah Unciano Lund, Supervisor, a copy of this report was given.
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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