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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803136
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:29:57 AM

Document Has Been Signed on 05/26/2022 11:29 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:LIFE CONNECTION-DEVON HOMEFACILITY NUMBER:
216803136
ADMINISTRATOR:ZHU, SHERRYFACILITY TYPE:
735
ADDRESS:371 DEVON DRIVETELEPHONE:
(415) 350-6636
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Administrator, Sherry ZhuTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Life Connection-Devon Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Sherry Zhu, and was granted access into the facility.

LPA toured the facility with the Administrator. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on June 2021 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured at 106 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 clients bathrooms. There was a sufficient supply of both perishable and non-perishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility laundry room. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. LPA observed a pool on premises that has a motorized tarp. Administrator walked on tarp and confirmed that the pool is secure and it isn't accessible to clients in care. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Facility staff has not been N95 Fit tested (See LIC 9102)

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LIFE CONNECTION-DEVON HOME
FACILITY NUMBER: 216803136
VISIT DATE: 05/26/2022
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LPA requested the following documents to be sent to CCL:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond (if any)
Most up-to-date Liability insurance
Control of Property
Register of Residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the Administrator due to printer issues/error.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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