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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801686
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:22:57 PM

Document Has Been Signed on 12/06/2023 03:22 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:ALDERSLYFACILITY NUMBER:
216801686
ADMINISTRATOR:SHANNON BROWNFACILITY TYPE:
741
ADDRESS:326 MISSION AVENUETELEPHONE:
(415) 453-7425
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 137CENSUS: 67DATE:
12/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director/Administrator, Shannon Brown and Health and Wellness Director, Melanie FennTIME COMPLETED:
12:45 PM
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director/Administrator Shannon Brown, and Health and Wellness Director Melanie Fenn. Upon arrival, LPA was informed that there were 67 Residents in care and 9 staff members on-site.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed staff files, resident files and resident medications. Files were found to be well organized, thorough, and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was found to be centrally stored and secure. LPA conducted interviews.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Saturday, 01/06/2024.

Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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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