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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800416
Report Date: 01/12/2024
Date Signed: 01/12/2024 02:53:08 PM

Document Has Been Signed on 01/12/2024 02:53 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:
01/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Queen Ann GougherTIME COMPLETED:
03:05 PM
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At approximately 9:35AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to continue an annual required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Administrator, Queen Ann Gougher arrived at approximately 10:30AM.

LPA reviewed 5 client files. Client files were observed to be in an unlocked cabinet accessible to clients. LPA reminded Administrator that client files are confidential and should not be accessible. LPA reviewed 5 staff files. Staff files were not immediately accessible as they are not stored physically on site. However, Manager of Program Operations, Kayla Hotchkiss, arrived at facility to assist LPA and was able to access files on their computer. Staff had required First Aid/CPR certificates. Per conversation with Manager of Program Operations, facility personnel are in the process of moving specific files into a binder to store on site for Community Care Licensing (CCL) to access whenever necessary. Last fire/ disaster drill was conducted 12/30/2023. LPA and Administrator reviewed client cash resources. LPA reviewed medications and medication records.

One of two carbon monoxide detectors that were tested was not operational during visit. Administrator discussed with LPA that the maintenance worker is scheduled to visit today and will be replacing it. Bathroom tile observed during visit dated 01/05/2024 has not yet been repaired. Per conversation with Administrator, facility is in the process of figuring out if they will have to update the entire bathroom or replace the tiles that have come off. Administrator stated that it is possible that when the bathroom was previously updated the floor did not get waterproofing underneath the tile, resulting in water damage. Facility is scheduled to have a general contractor come out on 01/13/2024 to inspect the tile and assess what action needs to be taken. Administrator to provide LPA with what information is provided during the assessment, as well as what action will be taken to repair tile.


Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 216800416
VISIT DATE: 01/12/2024
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Continued from LIC809

LPA had a conversation with Administrator about ensuring that prior to any construction to the home, Administrator must notify CCL in writing of their plans for construction as well as provide CCL with a plan for ensuring health and safety of clients during construction.

Administrator certificate for Administrator, Queen Ann Gougher 6011637735 expired on 01/05/2024. Administrator submit recertification paperwork and is waiting to get onto the Departments pending list.

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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