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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800098
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:12:14 PM

Document Has Been Signed on 12/16/2024 03:12 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: 8DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator/House Manager, John Coleman TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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At approximately 9:40AM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Charles Boomer, and House Manager, John Coleman. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance for 6 Ambulatory Clients and 2 Non-Ambulatory Clients for a total capacity of 8 clients. Upon arrival, LPAs was informed there were 8 clients in care and 3 staff members on-site.

At approximately 9:55AM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:10AM, LPAs conducted a walk-though of the facility with House Manager. LPAs observed the following: Facility was at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 2 story building with 4 client bedrooms, 3 client bathrooms, a staff room, an office, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Toxins and other dangerous items were observed to be stored inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected January 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

LPAs reviewed staff and client files. Staff files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. During client record review, LPAs observed that 3 of 4 clients did not have an updated needs and services plan, and 4 of 4 clients did not have signed personal rights (deficiency cited, LIC809D, Regulation 81070(b)). Administrator's Certificate for John Coleman (7017939735) is current with an expiration date of 01/06/2025.

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



Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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Document Has Been Signed on 12/16/2024 03:12 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 12/16/2024 at 02:18 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81070(b)
81070 Client Records
(b) Each client record shall contain the following information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by: Based on record review and observations, Licensee did not comply with the section cited above. LPAs observed that 3 of 4 clients did not have an updated needs and services plan, and 4 of 4 clients did not have personal rights on file. This poses a potential health and safety risk to residents in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee to submit paperwork (updated needs and services plan and signed personal rights) to CCL for identified clients by POC due date of 12/27/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STEPHANIE DRAPER HOUSE
FACILITY NUMBER: 216800098
VISIT DATE: 12/16/2024
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Continued from LIC809

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC811 (Confidential Names), and Appeal Rights discussed and provided to House Manager. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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