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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804258
Report Date: 08/27/2024
Date Signed: 08/27/2024 01:01:34 PM

Document Has Been Signed on 08/27/2024 01:01 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:HAYES HOUSEFACILITY NUMBER:
216804258
ADMINISTRATOR/
DIRECTOR:
SCUTT, JACQUES PFACILITY TYPE:
735
ADDRESS:5 HAYES STTELEPHONE:
(415) 847-2087
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 0DATE:
08/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Applicant, Jacques P. ScuttTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 08/27/2024 Licensing Program Analysts (LPA's) Loera and Felias conducted a pre-licensing inspection and was greeted by Licensee Applicant Jacques P. Scutt. This pre-licensing inspection is being conducted for an initial licensing. The facility is a one-story home with a fire Clearance has been approved for 6 ambulatory clients.

LPA's conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. LPA's observed Fire extinguishers throughout the facility which were last inspected November 2023. Cleaning products, sharp items, other toxins and chemicals are kept out of client access and found secured in the garage and storage closet. Additional supply of hygiene products available to clients. Per conversation with Licensee, they are currently living in the staff room on-site with their young children. Licensee discussed with LPAs they have a house they will be moving to once licensed. Water was measured at 114.1 degrees F in faucets used by clients which is within regulation between 105 & 120 degrees F.

Emergency exits along the both side of the facility have appropriate hardware and found to be unobstructed. However, during outside inspection, LPAs observed that the emergency exit 2 pathway was narrow and next to a steep hill (pictures taken). LPAs observed that clients have access to the pathway by using the backyard deck and saw that there were no safety measures in place to ensure that clients do not fall down the hill. Per conversation with Licensee, clients would only be allowed on the backyard deck. In the event of emergency, clients and staff would use emergency exit 1, located on the right side of the house. Licensee intends to renovate the hill in the future for client use. The Department will review the pictures taken to determine if the identified area must be physically inaccessible to clients.
Facility's smoke detectors are hardwired. They were last tested August 2024. LPAs confirmed that contents of the facility's First Aid Kit were sufficient. Component III was reviewed with Applicant.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Adult Residential Facility once review of pictures has been conducted. LPAs will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided to Applicant. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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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