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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102856
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:41:00 AM

Document Has Been Signed on 07/11/2024 11:41 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/
DIRECTOR:
MICHAEL SUSFACILITY TYPE:
735
ADDRESS:16 PORTEOUS AVENUETELEPHONE:
(415) 457-3690
CITY:FAIRFAXSTATE: CAZIP CODE:
94930
CAPACITY: 6CENSUS: 6DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Michael Sus, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual inspection to this facility and was welcome by staff Cheryl. 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 7/11/2024 at 8:40 AM with staff, 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 12/19/2023 at the time of the visit. Facility smoke detectors and carbon monoxide are combined and throughout facility and were found to be functioning properly at the time of the visit. Hot water temperature measured between 113.5 degrees F and 114.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 7/11/2024. 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 sample review of five clients and four staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 9:30 AM on 7/11/2024 and learned that 5 of 5 clients have updated Care Plans and physician’s report's. 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. P& I money is not co-mingled, and ledgers are current.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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: 07/11/2024
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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 7/11/2024 at 10:30 AM.

LPA conducted a sample review of staff records on 7/11/2024 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. Michael Sus Administrator Certificate # 6018707735 expires on 7/25/2024.

Disaster Drills have been conducted quarterly with the last one being conducted on 7/4/2024.

No deficiencies were cited during inspection.

LPA is requesting the following documents be submitted to CCL in order to update facility file by 7/25/2024:



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 (if changed)
LIC 9020 Register of Facility clients
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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