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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110612
Report Date: 04/17/2024
Date Signed: 04/17/2024 10:44:27 AM

Document Has Been Signed on 04/17/2024 10:44 AM - 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:JEAN'S CARE HOMEFACILITY NUMBER:
480110612
ADMINISTRATOR/
DIRECTOR:		JEAN STEPHENSFACILITY TYPE:
735
ADDRESS:526 APOLLO COURTTELEPHONE:
(707) 642-1283
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Jean StephensTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Licensee/Administrator Jean Stephens.

This facility has a fire clearance for four ambulatory and two non-ambulatory residents. There are currently four residents. There is a ramp for the front door. The backyard is very large. There are ramps around the backyard. There is an ample supply of perishable and nonperishable food. Resident rooms and common areas were toured.

A few topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 2, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule


no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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