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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800098
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:14:26 PM

Document Has Been Signed on 01/21/2025 03:14 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: 8DATE:
01/21/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Administrator/House Manager, John Coleman TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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At approximately 1:25PM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Charles Boomer, and House Manager/Administrator, 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 2 staff members on-site.

At approximately 1:35PM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs reviewed client medication. Medication was centrally stored and secure. During visit, House Manager/Administrator informed LPAs of an incident that occurred on 01/05/2025. Per discussion with Administrator, Client 1 (C1) had a fall which resulted in an shoulder fracture. House Manager/Administrator was able to provide a copy of the completed incident report to LPAs but was unable to provide proof that it had been submitted to the Department within the required timeframe. LPAs reviewed reporting requirement regulation with facility (technical violation issued, LIC9102, regulation 81061(b)(1)(D)). Per Administrator and Facility Staff, C1's care is being re-assessed.

LPAs 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 2/21/2025.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisories/Violations), and LIC811 (Confidential Names) discussed and provided to House Manager/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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