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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 09/23/2021
Date Signed: 09/23/2021 10:24:39 AM

Document Has Been Signed on 09/23/2021 10:24 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:D STREET RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109691
ADMINISTRATOR:STEFEN HAINBUCHFACILITY TYPE:
735
ADDRESS:527 D STREETTELEPHONE:
(415) 454-9920
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 10CENSUS: 9DATE:
09/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Stefen HainbuchTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at D Street Residential Support Services for the purpose of inspecting the renovated bathroom tub. LPA met with Counselor, Anders Helmersson and was granted access into the home.

On June 28, 2021, Administrator notified Community Care Licensing Division that a bathroom will be under renovation. The extent of the renovation was a replacement of the bathroom tub. LPA inspected the bathroom tub and observed no concerns at this time. LPA observed no visible leaks when the shower was turned on at the time of the inspection. LPA checked water temperature and found it to be at an appropriate temperature between 105-120 degrees. In addition, LPA inspected the bathroom for any hazardous items. LPA found no hazardous items present in the bathroom. LPA observed the bathroom to be clean and sanitary at the time of the inspection and ready for use.

No deficiencies were observed or cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report will be emailed to the Facility Administrator, Stefen Hainbuch and Counselor, Anders Helmersson.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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