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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803766
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:09:16 AM

Document Has Been Signed on 01/20/2023 10:09 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AZALEA HOUSEFACILITY NUMBER:
236803766
ADMINISTRATOR:AYALA, ALMIDAFACILITY TYPE:
740
ADDRESS:209 AZALEA CIRTELEPHONE:
(707) 964-4940
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Almida AyalaTIME COMPLETED:
10:25 AM
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an SOC 341, Report of Suspected Dependent Adult/ Elder Abuse, form that was submitted to CCL on 01/17/2023. LPA met with Administrator Almida Ayala, interviewed staff and reviewed records. This incident involved Client 1, C1, throwing a cup of juice at Client 2, C2, while they were sitting at the dinner table in anticipation of the meal. Staff immediately intervened to ensure the safety of the clients, by separating them. C2 was not injured during this incident and staff stayed with them to provide emotional support. C1 went to their room to calm down. Facility is working with Redwood Coast Regional Center, RCRC, to provide behavioral services and counselling for C1 to prevent future outbursts.
LPA received copies of documents.
No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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