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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803488
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:33:33 PM

Document Has Been Signed on 01/30/2025 03:33 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CASA RENE SOCIAL REHABFACILITY NUMBER:
216803488
ADMINISTRATOR/
DIRECTOR:		CEDRIC JACKSONFACILITY TYPE:
772
ADDRESS:1109 SIR FRANCIS DRAKE BLVDTELEPHONE:
(415) 256-9995
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 10CENSUS: 9DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Balakimwe Farara, Team LeadTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At 9:15 AM License Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1-year inspection of facility. LPA was welcomed by Mental Health Counselor (MHC) Elizabeth Roggeveen and Case Manager (CM) Elissa Gensburg. There are nine clients currently at the facility. This social rehabilitation facility is a 28-day program designed to provide transition and stabilizing services to adult clients. LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. Administrator/Program Director Cedric Jackson was not at the facility during the inspection.

At 10:00 AM, LPA began the facility tour with MHC Roggeveen. Random bedrooms inspected had appropriate furnishings per Title 22 Regulations. There are two bathrooms for clients that were inspected. The hot water temperature in client’s bathrooms measured between at 105 degrees F and 120 degrees F within Title 22 regulations. LPA observed that two (2) of two (2) clients' bathrooms did not have waste receptacles with tight fitting covers. A Technical Violation (TV) was issued for the waste receptacles not being in compliance. Toxic cleaning supplies are stored in a locked closet located in the laundry room. Perishable and nonperishable food supplies were sufficient to Title 22 Regulations of 2 days of perishable and 7 days of nonperishable. Knives are kept locked in drawer in staff office area. The kitchen and dining area was organized and free of clutter. The facility is well lit and at a comfortable temperature. The facility was clean and well maintained, with housecleaning service conducting a once a month deep clean. During the month a sign up sheet for house chores/cleaning is filled in by clients to complete and those not are done by clients are completed by staff. There is a large multipurpose room used for client meeting and activities. A large seating area where clients may congregate, or staff are able to hold group meetings is located off the kitchen/dining area. During the facility tour Team Leader (TL) Balakimwe Farara arrived at the facility.
The facility has a locked medication room. Medications are stored in a locked cabinet within the room. There is also a metal locked box stored within the medication cabinet for any medication that requires a third lock.
Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CASA RENE SOCIAL REHAB
FACILITY NUMBER: 216803488
VISIT DATE: 01/30/2025
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...Continued from 809
The Facility has a multi pull station fire alarm with audible/visual notification. Facility has fourteen integrated carbon monoxide/smoke alarms and sprinklers. The central Fire and Alarm system was last serviced on 1/29/2025. All fire extinguishers were found to be charged and last inspected on 1/1/2025. Disaster Drills are conducted monthly with the last being 12/6/2024. At 11:30 AM LPA reviewed of five (5) clients records. LPA observed that five (5) of five (5) clients records were current including: admission agreement, client personal rights, health assessment and care plan. LPA also reviewed five (5) staff records. LPA observed that five (5) of five (5) staff records had all required documentation including annual training requirements. There is at least one staff member per shift with current 1st Aid and CPR certifications. LPA spot checked the Centrally Stored Medications for three (3) Clients. Three (3) out of three (3) clients' medications were observed to be properly documented and given according to physicians’ directions.

LPA is requesting the following documents submitted to CCLD by 2/28/2025:

LIC 500 Personnel Report
LIC 309 Administrative Organization
LIC 308 Designation of Facility Responsibility
LIC 610D Emergency Disaster Plan

No deficiencies cited during today's visit. Exit interview conducted with TL Farara and Administrator Cedric Jackson via telephone.

LPA told Administrator Jackson to review the following Adult Care, Social Rehabilitation Facilities Regulations:

Article 05.Enforcement Provisions (Reserved): 80152 Deficiencies in Compliance

Article 06.Continuing Requirements: 81064 Administrator Qualifications & Duties

Copy of report and LIC9102 (Technical Violations/Advisories) discussed and provided to TL Farara. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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