<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102856
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:50:50 AM

Document Has Been Signed on 06/16/2023 11:50 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: 6DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michael Sus, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by staff Michael Francis. Administrator Michael Sus was contacted by staff and arrived during the visit. Clients had left to attend their day programs at the time of the visit. There are 6 clients in the facility.

LPA toured the facility on 6/16/2023 at 8:45 AM with staff Michael Francis, 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 12/22/2022 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 109.7 degrees F and 111.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 6/16/2023 at 8:55 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility kitchen. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads.

A review of five clients and a sample review of four staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 9:30 AM on 6/16/2023 and learned that 5 of 5 clients have an updated reappraisal/needs & care plan and physician’s report. P&I's are kept on a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingle, and ledgers are current on 6/16/2023.


Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/16/2023 11:50 AM - It Cannot Be Edited


Created By: Shannan Hansen On 06/16/2023 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LIFEHOUSE-COMITO
FACILITY NUMBER: 210102856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Administrator and record review, the licensee did not comply with the section cited above in 2 (staff - S1 & S2) out of 4 First Aid certificated were expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Administrator to ensure that staff S1 & S2 obtain First Aid Certification as required by regulation. Submit proof of staff's current active certification, copies of First Aid Cards showing names & dates, no later than 6/30/23, Plan of correction(POC) due 6/30/23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 06/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medications were centrally stored in a locked cabinet in the facility office. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 6/16/2023 at 9:45 AM. Centrally Stored Medication Records (CSMR) on 6/16/2023 at 9:50 AM currently for 2 out of 2 clients in the facility.

LPA conducted a sample review of staff records on 6/16/2023 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of CPR & 1st Aid certification for staff records; although 2 of 4 staff (S1 &S2) do not have current First Aid Certificates (see LIC809-D). Michael Sus Administrator Certificate # 6018707735 expires on 7/25/2024.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time other than facility email needs to be changed. Disaster Drills have been conducted often with the last one being conducted on 3/17/2023.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

LPA is requesting the following documents be submitted to CCL in order to update facility file by 7/11/2023:



LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
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: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3