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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800098
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:45:03 PM

Document Has Been Signed on 12/28/2023 12:45 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: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Staff Member, William Gavgavian, and Assistant Program Director, John AhrensTIME COMPLETED:
12:55 PM
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, William Gavgavian. Assistant Program Director, John Ahrens, arrived during visit at approximately 11:45AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 8 Ambulatory Clients. Upon arrival, LPA were informed there were currently 5 clients in care and 1 staff member on site.

At approximately 9:30AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 9:45AM, LPA conducted a walk-though of the facility with Staff Member and observed the following: Facility is a 2 story building with 4 client bedrooms, 3 client bathrooms, a staff room and bathroom, office spaces and common spaces. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPA observed that trash cans located in client bathrooms did not have lids but trash cans in the common spaces did (See LIC9102, Technical Advisory, Regulation 80088(f)(1)). LPA also observed that facility does not have an evacuation chair as required. (See LIC9102, Technical Advisory, HSC1565(f)(1)).

At approximately 11:00AM, LPA reviewed Client Files. All files were all found to be well organized, thorough and contained the required documentation. Facility does not do P&I monies for clients. Administrator's Certificate (6050593735) for John Coleman was current with an expiration date of 01/06/2025.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098
VISIT DATE: 12/28/2023
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Continued from LIC809

Fire extinguishers were last inspected January 2023.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC9102 (Technical Advisories) discussed and provided to Assistant Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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