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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110612
Report Date: 04/13/2023
Date Signed: 04/13/2023 01:29:19 PM

Document Has Been Signed on 04/13/2023 01:29 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:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Jean StephensTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with Administrator, Jean Stephens.

LPA toured the building and grounds which was found to be clean at a comfortable temperature and in good repair. All walkways and exits were observed to be unobstructed. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured 115 degrees F which are within the required regulation range of 105 to 120 degrees F.
Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients.. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in medication file cabinet.

Fire extinguishers were last serviced 10/1/2022. Smoke/Carbon Monoxide detectors were operational. Most recent fire/disaster drill was conducted April 2, 2023

Staff and Client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Jean Stephens expired 3/30/2023 and Administrator provided proof they sent in their renewal paperwork, but were told they are behind in processing renewals and there may be a delay. Medications and medication records were reviewed.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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: JEAN'S CARE HOME
FACILITY NUMBER: 480110612
VISIT DATE: 04/13/2023
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Continued from LIC809

Administrator and LPA discussed their Emergency Disaster Plan, Infection Control Plan and discussed the recent PIN that allows facilities to discontinue Covid-19 screening. Facility will update Infection Control plan of operation if there are changes they want to update.

Licensee/Administrator to submit updates of the following documents by 5/10/2023.



LIC 500 Personnel Summary
LIC9020 Register of clients
LIC400 and Copy of Surety Bond
Emergency Disaster Plan


No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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