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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800098
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:26:59 PM

Document Has Been Signed on 10/06/2021 01:26 PM - 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:STEPHANIE DRAPER HOUSEFACILITY NUMBER:
216800098
ADMINISTRATOR:JOHN COLEMANFACILITY TYPE:
735
ADDRESS:51 SAN PABLO AVENUETELEPHONE:
(415) 491-0249
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 8CENSUS: 8DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, John ColemanTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Stephanie Draper House Unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, John Coleman and was granted access into the facility. Upon entry, LPA observed a blue Building Permit issued by the County of Marin that was not reported to Licensing regarding an alteration to the building (See LIC 809D).

LPA toured the facility with Administrator, John Coleman. 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 July 2020 at the time of the visit (See LIC 9102). Smoke detectors and fire sprinklers are hard wired, and annual inspection records will be submitted to the Department. LPA observed 3 Carbon monoxide detectors were found to be operational during the visit. However, one Carbon monoxide detector was missing in the living room (See LIC 809D). There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between within Title 22 acceptable regulation while touring facility. 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 in the facility kitchen under the sink. Dangerous items such as knives were stored, but accessible to clients (See LIC 809D). 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 facility is aware that mattress pads need to be available for clients as required by Title 22 Regulations # 85088(c)(4). (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098
VISIT DATE: 10/06/2021
NARRATIVE
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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required and are in the process of obtaining N95 Fit testing for staff. LPA requested a new Emergency Disaster Plan along with a facility sketch to be forwarded to the Rohnert Park Regional Office.

Deficiencies were observed and cited on October 6, 2021 from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given to the Administrator. Exit interview was conducted and a copy of this report was signed by the Administrator and emailed to the Administrator, John Coleman.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 01:26 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/06/2021 at 12:35 PM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of an unlocked draw with knives, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Staff immediately locked drawer. Administrator to arrange training will an outside trainer to hold training with all staff regarding Care of Clients in Adult Residential Facilities. In addition Administrator will update their policy and procedures and how they will ensure their safety and plan for future compliance. Licensee to submit plan for training including topics covered, date of training & trainer to CCL by POC date of 10/07/2021 . Proof of training topics, trainer, time spent & roster of attendees, updated policy & procedures & plan for future compliance due to CCL by 10/13/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 01:26 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/06/2021 at 12:39 PM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
1503.2 Carbon Monoxide detectors required

This requirement is not met as evidenced by:
Deficient Practice Statement
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**Based on observation the faciity have 1 of 1 carbon monoxide not functioning properly at the facility which poses a potential health & safety risk to clients in care. LPA toured facility w/ staff and tested carbon monoxide which wasn't functioning in the living room and missing the cover.
POC Due Date: 10/13/2021
Plan of Correction
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Facility to ensure that carbon monoxide is operational and functioning. Facility to place a functioning carbon monoxide in the facility and submit a plan for future compliance by POC due date of 10/13/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 01:26 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/06/2021 at 12:42 PM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement was not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an interview with the Administrator, Administrator stated that Licensee failed to notify Licensing of proposed modifications which poses a potential healthy, safety and personal rights risk to clients in care. In addition, upon entry LPA observed a blue placard that read "Building Permit."
POC Due Date: 10/13/2021
Plan of Correction
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Licensee/Administrator to ensure Licensing is notified prior to any alterations to facility. Licensee to submit LIC 200 along with an Emergency Disaster Plan by October 13, 2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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