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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570316115
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:15:06 PM

Document Has Been Signed on 10/13/2022 03:15 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:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:KATHY B. NEESERFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 130CENSUS: 86DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kathy Neeser, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility, The Californian and met with Administrator Kathy Neeser. There were 86 residents present.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. LPA was shown facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 06/01/2022 at the time of the visit. A Fire Alarm and Life Safety System Inspection was completed on 08/2022 and the system was found to within acceptable results. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins and Cleaning Supplies are locked in the Housekeeping Storage Closet. Dangerous items were stored inaccessible to clients. There was a supply of hygiene products and paper products available for clients. All clients' bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan that was reviewed and approved on 09/09/2020. The Infection Control Plan was submitted on 09/30/22. Posters have been placed at entrance; hand sanitizer, a digital non-touch thermometer and screening questionnaire are placed at entrance for both residents and visitors. Staff do temperature and symptom checks before their shift. The Californian is participating in Surveillance Test They have an ample 30-Day supply of PPE and have had staff participate in N-95 Fit Testing.

There were no deficiencies found at the time of inspection.

No citations were issued.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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