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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800622
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:29:22 AM

Document Has Been Signed on 03/16/2022 11:29 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JEAN'S CARE HOME IIFACILITY NUMBER:
486800622
ADMINISTRATOR:DEARMON, JEAN/LARUE, CARLAFACILITY TYPE:
735
ADDRESS:1122 TUOLUMNE STREETTELEPHONE:
(707) 557-9422
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 3DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bobbie Dearmon, Lead StaffTIME COMPLETED:
11:15 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 Lead Staff Bobbie Dearmon (BD). Additional Lead Staff Robert Stephens arrived during the visit. The facility currently provides care for three (3) clients 2 of which were in the facility and one of which was out in the community 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 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 Extinguishers were found to be purchased on 5/12/2021 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 stored under kitchen and separate storage area. There was an ample supply of hygiene products and paper products available for client use. All client’s bedrooms have lighting & appropriate furnishings. Hot water measured at 116.2 and 117.3 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients.

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. Hard copy of the report was sent to Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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