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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800416
Report Date: 02/15/2022
Date Signed: 02/16/2022 09:49:32 AM

Document Has Been Signed on 02/16/2022 09:49 AM - 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:SAN BENITO HOUSEFACILITY NUMBER:
216800416
ADMINISTRATOR:ANN GOUGHERFACILITY TYPE:
735
ADDRESS:6 SAN BENITO WAYTELEPHONE:
(415) 895-1624
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 3DATE:
02/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ann Gougher - AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and was welcome by Ann Gougher administrator during this visit. The purpose of the case management visit is to obtain additional information regarding incident report submitted to the Department. There are 3 clients in care during this visit.

Department learned that on 2/5/2022 client C1 admitted on 1/12/2022 left the facility unassisted at 8:40 AM and returned at 8:45 AM. Staff at the facility contacted the police who arrived around the same time as C1 and administrator. Staff spoke with C1 requesting for her not to leave facility unassisted, however; client C1 left anyway. GGRC and facility are looking for a one on one day program to place client C1. On Saturday February 5, 2022 there were 5 clients and 1 staff at facility. Physician’s report dated 1/2022 stated that resident is able to leave facility unassisted. Per staff and client C1, client is not happy to be at this facility and would like to live independent. Facility, client C1, and GGRC will be meeting on Thursday February 17, 2022.

There were no deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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