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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800622
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:42:39 PM

Document Has Been Signed on 02/24/2023 12:42 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 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: 2DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Lisa Fernandes, AdministratorTIME COMPLETED:
01:00 PM
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On 2/24/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Staff, Bobbie Dearman. Administrator, Lisa Fernandes arrived later in the visit. The facility currently provides care for 2 clients both of which were attending day program or out in the community at the time of visit.

LPA continued with a tour of the facility with Lead 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 Extinguisher located on each floor were found to be last charged on 10/1/2022 at the time of the visit. Smoke detectors in client bedrooms and throughout were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinets located in kitchen area. There was a supply of hygiene products and paper products available to clients upon request. Facility has restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in designated cabinets located in the hallway and found to be secured. Water was measured and found to be within Title 22 regulations at 105.4 degrees. F.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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 II
FACILITY NUMBER: 486800622
VISIT DATE: 02/24/2023
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Administrator, Lisa Fernandes 6036511735 certification is current and expires on 12/9/2023.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 3/10/2022:



LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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