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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800098
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:14:40 PM

Document Has Been Signed on 05/16/2024 12:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:STEPHANIE DRAPER HOUSEFACILITY NUMBER:
216800098
ADMINISTRATOR/
DIRECTOR:
JOHN COLEMANFACILITY TYPE:
735
ADDRESS:51 SAN PABLO AVENUETELEPHONE:
(415) 491-0249
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 8CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Staff Member, William Gavgavian, and Assistant Program Director, John AhrensTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Member, William Gavgavian and Administrator, John Coleman. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Upon arrival, LPA were informed there were currently 8 clients in care and 2 staff members on site.

At approximately 9:20AM, 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. LPA reviewed staff files and medication. Staff files were all found to be well organized, thorough and contained the required documentation. Staff have current first aid/CPR certification. Medication was observed to be centrally stored and secure.

Facility's last emergency/disaster drill was February 2024. Facility's fire system was last inspected January 2024.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 06/16/2024.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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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