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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102856
Report Date: 06/14/2022
Date Signed: 06/15/2022 10:34:48 AM

Document Has Been Signed on 06/15/2022 10:34 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:LIFEHOUSE-COMITOFACILITY NUMBER:
210102856
ADMINISTRATOR:MICHAEL SUSFACILITY TYPE:
735
ADDRESS:16 PORTEOUS AVENUETELEPHONE:
(415) 457-3690
CITY:FAIRFAXSTATE: CAZIP CODE:
94930
CAPACITY: 6CENSUS: 5DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michael Sus - Administrator TIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by Staff Cheryl “Cher” Evans. Staff called Administrator Michael Sus who arrived later. Facility has 5 clients at the moment, 2 were attending day programs during the visit. Three of facilities clients are back to attending day programs. Facility has outings for clients to parks, rivers and other activities during the day.

LPA arrived at the facility and her temperature checked and logged by staff Cher. All staff are temperature checked and logged each shift and wear masks. During facility tour on 6/14/2022 at 9:30 AM with staff Cher and then Administrator Michael Evans, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/29/2021 at the time of the visit. 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. Extra food in the back-spare building refrigerator is properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the office, behind locked door at the top of basement, in locked kitchen closet, and in locked spare backyard building. Medications are stored in locked cabinet in office. Facility has a 30-day supply of medication for clients There was a supply of cleaners, hygiene product, and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperatures measured within acceptable regulations of 105 to 120 degrees F from client’s bathroom faucets. Disaster drills are conducted monthly with the last one being 2-24-2022.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed throughout the facility. Entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work, logbook is kept in the office. Facility has PPE supply stored in outside shed and office. Facility has not hired or admitted any new clients since the start of the pandemic. Clients do not wear masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

Continued LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LIFEHOUSE-COMITO
FACILITY NUMBER: 210102856
VISIT DATE: 06/14/2022
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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Clients have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had PPE training required on file and have had N-95 fit testing.

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

LPA was presented with proof of current CPR & 1st Aid certifications


All staff have received COVID booster vaccinations
Administrator Certificate is for Michael Sus # 6018707735 Exp. 7/22/2022
LPA reviewed new PIN 22-18-ASC regarding Infection Control Plan due in CCL by 6/31/2022

There were no deficiencies found in the areas inspected.

LPA is requesting the following documents to be submitted to CCL in order to update facility file by 06/30/2022:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 400 Affidavit Regarding Resident Cash Resources

LIC 402 Surety Bond

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Client’s

Copy of Current Administrator's Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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