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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800261
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:04:06 PM

Document Has Been Signed on 01/26/2023 01:04 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:LIFEHOUSE-LAUREL PLACEFACILITY NUMBER:
216800261
ADMINISTRATOR:MIKE SUSFACILITY TYPE:
735
ADDRESS:210 LAUREL PLACETELEPHONE:
(415) 456-7141
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mike Sus, AdministratorTIME COMPLETED:
01:15 PM
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On 1/26/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Mike Sus. The facility currently provides care for 6 clients all of which were attending day program at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found throughout the facility and to be last charged on 12/22/2022 at the time of the visit. Smoke and carbon monoxide detectors were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked facility garage and maintenance closets. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides all hygiene product to clients when requested. Facility has restrooms equipped with paper towel dispenser and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in the facility office and found to be secured. LPA measured water at faucets accessible to clients which measured between 108.6 and 117.8 degrees F which is within Title 22 regulations between 105 and 120 degrees F.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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: LIFEHOUSE-LAUREL PLACE
FACILITY NUMBER: 216800261
VISIT DATE: 01/26/2023
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Infection Control:
Facility has completed an Infection Control Plan and will submit to CCLD for review. All residents and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and residents ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and residents are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 2/9/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility resident’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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