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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800261
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:49:01 PM

Document Has Been Signed on 01/31/2024 03:49 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:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:House Manager, Makela MooreTIME COMPLETED:
04:00 PM
NARRATIVE
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At approximately 2:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with House Manager, Makela Moore. Facility is an Adult Residential Home that provides care and assistance for Adults with Developmental Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed there were currently 6 clients in care and 1 staff member on site. LPA was also informed that all clients were out of the community attending Day Program.

At approximately 2:25PM, 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 2:30PM, LPA conducted a walk-though of the facility with House Manager and observed the following: Facility is a 3 story building with 4 client bedrooms, 4 1/2 client bathrooms, a staff room and office space, 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. LPA also observed that facility does not have an evacuation chair as required. (See LIC9102, Technical Advisory, HS&C 1565(f)(1)). Hot water temperatures for 1 of 5 sinks in facility were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's half bath sink measured at 100.5F (this deficiency has been cited, see LIC809D, Regulation 80088(e)(1)). Facility's fire extinguishers were last inspected December 2023. Facility's last fire drill was conducted December 2023.
LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

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

Exit interview conducted. Copy of report, LIC809D, LIC9102 (Technical Advisory), and Appeal Rights discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/31/2024 03:49 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 01/31/2024 at 03:25 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: LIFEHOUSE-LAUREL PLACE
FACILITY NUMBER: 216800261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, the Licensee did not comply with the section cited above. It was observed that 1 of 5 sinks in the facility measured at 100.5F. This poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 02/01/2024
Plan of Correction
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Licensee to submit a self-certification stating that the facility will order a new water heater and that a 10-day temperature log will be conducted upon its installation. Certification to be submitted by POC due date 02/01/2024. 10-day temperature log to show the following: temperatures to be checked twice a day, indicate sink location, and temperature reading to be submitted to CCL by 02/10/2024.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
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