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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800098
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:49:49 PM

Document Has Been Signed on 12/20/2022 02:49 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 7DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Charles Boomer, MHC 1TIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at Stephanie Draper House unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Charles Boomer, MHC1, and was granted access into the facility.

LPA toured the facility with Chris Boomer. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Smoke detectors and fire sprinklers are hard wired, and annual inspection records will be submitted to the Department. LPA observed 2 carbon monoxide detectors and they 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. 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 and inaccessible to clients. The bathrooms designated for clients at the facility were supplied with paper towels and hand soap. All clients' 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). Facility has PPE supply stored in the storage office located in the staff room. LPA requested the following documents:

LIC 500
Latest Fire Sprinkler and Extinguisher Inspection by Fire Department/Vendor
Proof of Liability Insurance
Resident Roster
Employee Roster

No citations were issued at the time of inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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