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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803863
Report Date: 09/14/2021
Date Signed: 09/14/2021 11:09:23 AM

Document Has Been Signed on 09/14/2021 11:09 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:TENDER RESIDENTIAL HOMEFACILITY NUMBER:
216803863
ADMINISTRATOR:NDOMO, RODRIGUEFACILITY TYPE:
737
ADDRESS:257 BLACKSTONE DRIVETELEPHONE:
(628) 253-5468
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 3CENSUS: 3DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Nurse, James Lafon & Administrator, Rodrigue NdomoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived Unannounced at Tender Residential Home for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Nurse, James Lafon. Nurse granted access into the facility. Administrator, Rodrigue Ndomo arrived 13 minutes afterwards.

LPA toured the facility and found that the facility is a one floor building. It 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 2/2021. First aid kit was inspected and appropriate at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit and are hard wired. Facility has sensor faucets in client's bathrooms. Hot water temperature checked in automatic water heater measured 115 degrees F at the time of the visit. The facility has a phone line designated for client use. There was an ample supply of personal hygiene products. Personnel records and client records are stored at the facility cabinet in the living room area. The main floor includes kitchen, dining area, computer area, Activities calendar is posted for facility activities and individual activities monthly & weekly. Client records, medication, first aid supplies, and toxins will be locked on this level. Dangerous items were stored inaccessible to clients. There are two bathrooms. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. The floor will also consist of a laundry room, and storage areas in the garage. LPA requested the following documents be updated and sent to licensing, LIC 309, LIC 400, LIC 308, LIC 500, LIC 402 and Liability Insurance.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the office located in the backyard. Facility is in the process of being N95 Fit tested. 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 facility Administrator, Rodrigue Ndomo
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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