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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800558
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:40:46 PM

Document Has Been Signed on 03/26/2024 02:40 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:GRIFFIN FAMILY CARE HOME - UDELLFACILITY NUMBER:
486800558
ADMINISTRATOR:GRIFFIN, JOETTA AND EDWARDFACILITY TYPE:
735
ADDRESS:4692 UDELL ROADTELEPHONE:
(707) 446-2512
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 6DATE:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gabriella Eschevarria, General Manager and John Catacutan, House ManagerTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Jill Nakagawa and Stefanie Mutialu arrived unannounced on 03/26/2024 to conduct a required 1 - year inspection. LPAs met with House Manager, John Catacutan and General Manager Gabriella Eschevarria. Clients were not present during inspection, they were attending day programs.


LPAs toured the facility and found it clean, organized and well-maintained. The property has multiple sheds and buildings, which are used to store tools and paints,which were all locked and secured. Exits and walkways were clear from obstructions. Facility has a sufficient amount of perishable and nonperishable food. Soaps, cleaning supplies and other toxins were locked and secured. Medications were locked and secured. Fire extinguishers were charged and current, and inspected on 3/12/2024. The last Fire Drill was conducted on 3/11/2024.
Staff and client files were reviewed and found to be complete.


Facility will be changing administrators and submitting the required documentation within the next 10 days. In addition, facility will be working with residents to update their inventories of belongings.

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SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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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: GRIFFIN FAMILY CARE HOME - UDELL
FACILITY NUMBER: 486800558
VISIT DATE: 03/26/2024
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LPAs requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 400 Affidavit regarding client cash resources
LIC 402 Surety Bond
Water Analysis Test Results
Theft and Loss Policy and Procedures Update
Transportation Procedures Update
Plan for Incidental Medical and Dental Care Update

Exit interview conducted with General Manager and a copy of this report provided to the facility. No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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