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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803505
Report Date: 06/28/2021
Date Signed: 06/29/2021 09:22:45 AM

Document Has Been Signed on 06/29/2021 09:22 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:TAKING THE JOURNEY LLCFACILITY NUMBER:
496803505
ADMINISTRATOR:DOSS, KISAFACILITY TYPE:
740
ADDRESS:512 CASA VERDE CIRCLETELEPHONE:
(707) 981-8751
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kelly Eriksen - LicenseeTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by staff Elia Cuevas. Licensee Kelly Eriksen arrived during the visit. There were 6 residents present at the facility.

LPA arrived at the facility and had temperature checked. All staff temperatures checked and logged each shift. Staff placed their masks once LPA arrived. LPA toured the facility with staff Elia Cuevas. During tour on 6/28/2021 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 4/2021 at the time of the visit. A sample of 1 out of 1 Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Hot water temperature measured 108.3 degrees F within acceptable regulations of 105 to 120 degrees F in 1 of 1 client’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted a mitigation program plan that is being reviewed at this time. Posters have been placed at facility. Facility has PPE supply stored in one of the residents’ bathroom. Residents’ medications are stored and locked in the office file cabinet. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: TAKING THE JOURNEY LLC
FACILITY NUMBER: 496803505
VISIT DATE: 06/28/2021
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In addition, facility has a designated area for visitors in the backyard, living room, and/or in the bedrooms when possible. Visits are been scheduled. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and still N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with licensee who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.


There were no deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC809 (FAS) - (06/04)
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