<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110612
Report Date: 03/03/2022
Date Signed: 03/04/2022 03:43:52 PM

Document Has Been Signed on 03/04/2022 03:43 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:JEAN'S CARE HOMEFACILITY NUMBER:
480110612
ADMINISTRATOR:JEAN STEPHENSFACILITY TYPE:
735
ADDRESS:526 APOLLO COURTTELEPHONE:
(707) 642-1283
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Jean StephenTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Jean Stephen, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There is currently 4 clients in care.

LPA toured facility and grounds with administrator and observed COVID-19 precaution signs posted in common areas to promote hand washing, cough etiquette. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for clients and staff, and 30-day PPE supply. Facility will follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Facility understands hand sanitizer should not be placed in the rooms of residents who lack hazard awareness and impulse control. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department on 9/16/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.
In addition, facility was found to be clean, at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged and serviced on May 10, 2021.

LPA requested facility staff to get N95 fit tested and will get additional information for facility.

Exit interview conducted with June Stephens.

No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1