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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800416
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:02:45 PM

Document Has Been Signed on 01/05/2024 03:02 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: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: 5DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Queen Ann GougherTIME COMPLETED:
03:15 PM
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At approximately 2:00PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an annual required inspection and was greeted by Administrator, Queen Ann Gougher.

LPA initiated a tour of the facility at approximately 2:15PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 114 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Additional cleaning supplies and disinfectants are stored in a locked closet which is inaccessible to clients in care. Facility has at least two days of perishable and one week of non-perishable foods which was stored per regulation and were of quality. Emergency food and water supplies are stored in the kitchen. Medications were centrally stored and locked.

Smoke alarms were tested and operational during visit. Fire extinguishers were last serviced May 2023.

LPA observed missing tiles as well as additional tile coming off the wall in main bathroom. Per conversation with Administrator, facility got an estimate for all tile in main bathroom to be replaced. At this time there is not a set date for repairs. LPA observed unlocked medication refrigerator and Administrator immediately locked the refrigerator.

LPA is unable to complete annual inspection at this time. LPA will return at a later date to complete inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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