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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803136
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:16:13 PM

Document Has Been Signed on 03/11/2025 03:16 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:LIFE CONNECTION-DEVON HOMEFACILITY NUMBER:
216803136
ADMINISTRATOR/
DIRECTOR:		ZHU, SHERRYFACILITY TYPE:
735
ADDRESS:371 DEVON DRIVETELEPHONE:
(415) 350-6636
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
03/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Administrator, Sherry ZhuTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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At approximately 2:45PM, Licensing Program Analysts (LPAs) Felias and Deniz arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Sherry Zhu. The purpose of the visit was to follow up a death report that was submitted to Community Care Licensing (CCL).

Death Report 1: CCL received a death report on 03/10/2025. Report states that Client 1 (C1) was taking a walk with facility staff and suddenly collapsed. Facility staff contacted emergency personnel. Facility made all appropriate notifications per regulation.

LPAs obtained additional documentation related to the incident. Facility to submit a copy of the Death Certificate to CCL when available.

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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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