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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406702
Report Date: 07/14/2021
Date Signed: 07/14/2021 04:22:02 PM

Document Has Been Signed on 07/14/2021 04:22 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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME:SOJOURNERS HAVEN GROUP HOME IIFACILITY NUMBER:
336406702
ADMINISTRATOR:GINA MELENDEZFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: 6DATE:
07/14/2021
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Sherrae Williams, Facility Manager IIITIME COMPLETED:
04:31 PM
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On July 14, 2021 at 2:00 PM, Licensing Program Analyst (LPA) Cindy Hamilton and Licensing Program Manager (LPM) Abdoulaye Traore conducted an annual inspection. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on 08/19/2021. LPA was met at the facility by Facility Manager II Debra Kennedy and later joined by Facility Manager III Sherrae Smith.

A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children’s recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked closet in the staff office. Licensee did not have provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client’s bathroom was measured to be 113 degrees.



Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Per facility staff, no firearms or weapons are allowed in the facility.
Based on observations the facility is being issued a technical violation of Title 22, Chapter 7.5, version 3.1, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87075(b)(1)(A) Health Related Services.
SUPERVISORS NAME: Abdoulaye Traore
LICENSING EVALUATOR NAME: Cindy Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME: SOJOURNERS HAVEN GROUP HOME II
FACILITY NUMBER: 336406702
VISIT DATE: 07/14/2021
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The licensee shall ensure that all prescribed medications, with the exception of contraceptives, are centrally stored, as provided in California Code of Regulations, Title 22, Section 80075. (1) Licensees shall continue to ensure the health and safety of all children in the facility. (A) The licensee shall provide the child with a locked container in which to store their contraceptives. The facility is also being issued a technical violation of , STRTP ILS section 87075(b)(1)(A)(1) Health Related Services (1) There shall be more than one key to the container. One key shall be given to the child and the others shall be kept by short-term residential therapeutic program staff.

An exit interview was conducted and a copy of this report and appeal rights were provided to Facility Manager III Sherrae Smith.
SUPERVISORS NAME: Abdoulaye Traore
LICENSING EVALUATOR NAME: Cindy Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
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