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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 01/23/2023
Date Signed: 01/23/2023 02:25:55 PM

Document Has Been Signed on 01/23/2023 02:25 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:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:TOOTLE, MICHELLEFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 5DATE:
01/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Savannah Finley (DSP)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst Cuadra arrived unannounced to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with staff Savannah Finley. Program Manager Andrea Jackson was not able to come to the facility, but she gave authorization for staff to sign the report.

LPA learned through interviews on 1/11/23 with current Administrator that their current job title is Quality Assurance Manager, and they are not present on the premises the number of hours necessary to manage and administer the facility in compliance per regulation. A technical violation will be issued to address the appointment of an Administrator for this facility.



During today’s visit, LPA followed up on a 30-day eviction notice dated 1/19/23 issued to client (C1) due to a significant change of condition and medical diagnosis needing a higher level of care. C1 was hospitalized on 1/9/23 where they were stable and they are currently receiving rehabilitation services at Novato Healthcare Center. Golden Gate Regional Center (GGRC) has agreed to provide additional staffing in the interim to locate placement opportunities for C1 and the facility will work collaboratively with GGRC to ensure the continuity of services is met until they find a placement to relocate C1. House Manager agreed to submit updated LIC500 Personnel Report indicating staff coverage.

Exit interview conducted with House Manager Andrea Jackson over the phone and a copy of this report was provided to staff.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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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