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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102381
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:37:48 PM

Document Has Been Signed on 04/28/2022 12:37 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:JO-MIL GROUP HOMEFACILITY NUMBER:
480102381
ADMINISTRATOR:CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:143 RUTGERSTELEPHONE:
(707) 553-1581
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Cheryl Davidson, AdministratorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by staff, Diane Mills (DM). Administrator, Cheryl Davidson (CD) was contacted and arrived during the visit. The facility currently provides care for four (4) clients all of which were at day program at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; facility 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 7/17/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are securely stored under kitchen sinks and in the laundry room. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water measured at 119.4 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients.

During the tour LPA observed window screens in clients' C1 & C2 bedroom with some minor wear. LPA issued Technical Violation and is requesting for Administrator to replace the screens and provide photo evidence of repairs. All staff have updated 1st Aid & CPR Training on file.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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: JO-MIL GROUP HOME
FACILITY NUMBER: 480102381
VISIT DATE: 04/28/2022
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Infection Control:
Facility has submitted a mitigation program plan which has been approved. All staff and clients have been vaccinated with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and clients are screened on a daily basis.

No deficiencies cited during today's visit.

Exit interview conducted with facility Administrator, whose signature on this document confirms receipt.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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