<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:49:58 AM

Document Has Been Signed on 12/23/2021 08:49 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:DUNA JOSON (AGSALOG)FACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 5DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michelle Meeks - staffTIME COMPLETED:
09:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. LPA was welcome by staff, Michelle Tootle - Manager of Program Operations was contacted on the phone. LPA met with Michelle Meeks - staff. Following item were learned/observed visits:

During visit on 12/17/2021, LPA learned that Duna Joson will no longer be the administrator at this facility per Michelle Tootle - Manager of Program Operations. Facility has submitted a new LIC 500 - Personnel Report. Department is requesting information for new facility administrator. The following is to be submitted to the Department ASAP:

LIC 215 Application Information
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
First Aid Certificate
Administrator Resume (in small facilities if possible)
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan for Residential Care Facilities for the Elderly
LIC 501 Personnel Record
LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed)
TB test that shows "negative" (keep on facility staff file to be reviewed)
LIC 508 Criminal Record Statement
LIC 9182 Criminal Record Exemption Transfer Request
Copy of Personal ID
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)
Detailed employment/Education history with Diploma Certificate

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 12/22/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In addition, on 12/17/21 facility didn't take LPA's temperature and at today's arrival staff had to look for the thermometer to take LPA's temperature. Per staff, no temperatures of staff at arrival and clients have been taken this morning. Facility must take temperatures of clients and staff at arrival daily and have it entered on a log for the Department to review.

There were no deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2