<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800622
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:08:44 AM

Document Has Been Signed on 03/28/2024 10:08 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 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:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Carla La RueTIME COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Carla La Rue.

This facility has a fire clearance for five ambulatory and one non-ambulatory. This building has three floors. There is a pool in the backyard that has the appropriate fence. There is an ample supply of perishable and nonperishable food. Staff and client records were reviewed

Several topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by April 17, 2024:
-LIC 308 designation of administrative responsibility
-current 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: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1