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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801218
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:58:29 PM

Document Has Been Signed on 03/19/2025 03:58 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:DOVER VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801218
ADMINISTRATOR/
DIRECTOR:
CECILIA JUANILLOFACILITY TYPE:
740
ADDRESS:752 ROSEMARY COURTTELEPHONE:
(707) 427-1105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Edward Gadia, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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At approximately 1:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management -- annual continuation visit to review resident files, staff files, and medications and medication logs, and met with Edward Gadia, House Manager.

At approximately 2:00 PM, LPA conducted file review. Four (4) staff and five (5) resident files were reviewed and LPA observed the following: Four (4) staff files reviewed were observed to have the required documentation per Title 22 regulations. LPA informed House Manager that all staff files shall have a physician health screening and proof of negative TB results and a record of the initial 40 hours of training completed to bring the facility back into compliance. The House manager agreed to bring the facility back into compliance with regulation immediately. All staff have proof of current First Aid and House Manager will have all staff complete CPR training to ensure there is always at least one CPR certified staff member on shift at the facility per regulation. LPA reviewed five (5) of five (5) resident files which were each observed to contain all the required documents per regulation. House manager agreed to ensure all care plans are reviewed and signed by each residents' responsible party no less than annually to remain in compliance with regulation.

House Manager states that the facility and residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. Medications and medication records were inspected and observed maintained in compliance with regulation. Facility does not handle P&I.

No deficiencies cited during today's inspection.

Exit interview conducted with House Manager whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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