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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804118
Report Date: 01/23/2023
Date Signed: 01/23/2023 01:38:45 PM


Document Has Been Signed on 01/23/2023 01:38 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:WALFORD RESIDENTIAL CAREFACILITY NUMBER:
576804118
ADMINISTRATOR:WALFORD, APRILFACILITY TYPE:
740
ADDRESS:616 LEWIS AVETELEPHONE:
(530) 665-6004
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:6CENSUS: 0DATE:
01/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:April Walford, Administrator and Rohan Walford, Owner TIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted a pre-licensing inspection on 01/23/2023. LPA met with Administrator/ Licensee April Walford and Rohan Walford, Licensee/Owner. The facility has a fire clearance approval from the Woodland Fire Department for 6 non-ambulatory residents. Facility will operate with 24-hour staffing and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· Lockable separate cabinets for medications, toxins, and knives/sharps.
· All exits were unobstructed.
· Carbon monoxide detector tested and observed to be operational at the time of inspection.
· First Aid kit, night-lights, and flashlights for emergency lighting were observed.
· Supply of linens, paper products, and hygiene supplies available; and perishable and non-perishable food, as required in Title 22.
· Grab bars and non-slip mats in 2 of 2 bathrooms; and water temperature in bathrooms and kitchen was between 105-111 F.
· 1 Fire Extinguisher fully charged, purchased on 09/15/2022, mounted in kitchen/dining room area. Hard-wired Smoke Detector System inspected by Woodland Fire Department on 09/26/2022.
· Administrator Certification was current as of 10/22/2022 Certificate # 6064397740.

Component III Orientation was completed during today's inspection.

Covid-19 Mitigation Plan and Infection Control Plan Has been submitted to Application Unit Analyst.

Pre-Licensing is complete. LPA will submit the pre-licensing report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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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