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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890100
Report Date: 10/30/2023
Date Signed: 10/30/2023 10:59:45 AM

Document Has Been Signed on 10/30/2023 10:59 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,
, CA
FACILITY NAME:MUIR WOOD - THOMPSON RANCHFACILITY NUMBER:
496890100
ADMINISTRATOR:SCOTT SOWLEFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: 0DATE:
10/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Scott SowleTIME COMPLETED:
11:15 AM
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On October 30, 2023 Licensing Program Analyst (LPA) Monica Pavia met with Chief Executive Officer/Administrator, Scott Sowle, for a prelicensing inspection.

LPA discussed the following with the Mr. Sowle:
Forms that the facility uses and will continue to use.
Corporate organization - Including chain of command and roles of staff
Written plans, policies or procedures that was submitted with the application.
Administrator/Director qualifications and duties.

Mr. Sowle informed this LPA that he will be the Administrator for Muir Wood - Thompson Ranch when the facility is licensed. Mr. Sowle will submit Change of Administrator paperwork to the Santa Rosa office LPA, once facility is ready for placement's.

1. Facility grounds inspected. Grounds are clean and free from observable hazard. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises.
2. Adequate indoor activity space and materials observed, and outdoor activity space was observed.
3. Chemicals were appropriately locked
4. Procedures for Locked and centrally stored medications observed.
6. Adequate storage space observed.
7. Individual beds in good repair observed. A supply of extra linens available for bed changes.
8. The house has 3 client bedrooms, double occupancy, located on the second floor. Bedrooms are accommodating of all required furnishings.
9. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. A supply of nonperishable foods were observed on this date.
10. Sample menu posted.
SUPERVISORS NAME: Carolyn Flynn
LICENSING EVALUATOR NAME: Monica Pavia
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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
CCLD Regional Office,
, CA
FACILITY NAME: MUIR WOOD - THOMPSON RANCH
FACILITY NUMBER: 496890100
VISIT DATE: 10/30/2023
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11. All appropriate forms posted within client view.
12. Dining room equipped with large table and chairs accommodating of all clients.
13. Facility has two restrooms for client use, one for staff use, all are operable Hot water measured 120 degrees on this date.

Applicant is associated through Guardian and has been fingerprint cleared. Prior to accepting
placement's, all staff must be fingerprint cleared and associated to the facility. Discussed Guardian process with the facility.

Discussed with the facility the process for changing the facility Administrator. The following documents are required:
1. LIC 308 (Designation of Facility Responsibility) designating new administrator.
2. Current Personnel Record for new Administrator.
3. Verification of Education and/or experience for new administrator.
4. Copy of current administrator certificate.
5. Current (within one year) health screening and TB test.
6. Board Resolution granting administrative responsibility to the new administrator.
7. Fingerprint association transfer request (if the Administrator is not already associated to the facility)

Discussed Incident reporting. An initial report for all reportable incidents is to be made by the next working day to crpincrohnertpark@dss.ca.gov. A full report is to be remitted within 7 days and may also be made to the incident reporting email. After licensure, you will receive a letter notifying you of your assigned LPA, from the Santa Rosa office.

The facility will be approved for initial Licensure as of today, October 30, 2023. Initial license will be issued on a provisional basis, expiring one year from effective date. License will be valid for up to 6 male and/or female youth ages 12 through 17.

A copy of this report was provided to Mr. Sowle.
SUPERVISORS NAME: Carolyn Flynn
LICENSING EVALUATOR NAME: Monica Pavia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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