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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803136
Report Date: 07/28/2023
Date Signed: 07/28/2023 12:49:30 PM

Document Has Been Signed on 07/28/2023 12:49 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: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: 6DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Staff Member, Johnnie ReidTIME COMPLETED:
12:55 PM
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At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Johnnie "JJ" Reid. Administrator, Sherry Zhu, arrived at approximately 10:35AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 6 Ambulatory Clients with a total capacity of 6 clients. Upon arrival, LPA was informed that there were 6 clients in care, with 5 clients out of the community attending Day Program. LPA was also informed that there were 3 staff members on site.

At approximately 9:30AM, LPA reviewed the Facility's Staff Roster and found that all staff on site were background cleared and associated to the facility per regulation. At approximately 9:45AM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 3 Client bedrooms, 1 staff room, 2 bathrooms, a kitchen, dining room, living room, and laundry area. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Fire extinguishers were last inspected June 2023. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire drill was conducted in April 2023.

At approximately 10:30AM, LPA reviewed 6 of 6 client records were all found to be well organized, thorough and contained the required documentation. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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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: 07/28/2023
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Continued from LIC809

At approximately 11:30AM, LPA reviewed a sample size of 6 staff records. First Aid and CPR certification were current for 6 of 6 staff files reviewed. Per conversation with Administrator, their Administrator's Certificate (6003088735) is pending. Staff Member, JJ Reid, has a current Administrator Certificate (6064620735) which expires 07/10/2024.

At approximately 12:00PM, LPA conducted staff interviews.

LPA requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of Sunday, 8/27/2023.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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