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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801797
Report Date: 11/28/2022
Date Signed: 11/28/2022 03:28:58 PM

Document Has Been Signed on 11/28/2022 03:28 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:SAMSON HOME CARE IIFACILITY NUMBER:
486801797
ADMINISTRATOR:SAMSON, EVELYNFACILITY TYPE:
735
ADDRESS:1943 MARSHALL RDTELEPHONE:
(707) 447-5624
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 4DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Joannalyn AgbayaniTIME COMPLETED:
03:38 PM
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Licensing Program Analyst (LPA) Walters arrived at the Adult Residential Facility (ARF) unannounced to conduct Required- 1 Year visit. Administrator, Joannalyn Agbayan (6043858735 exp 3/28/23) granted LPA entrance into the facility. Licensee, Evelyn Samson was not available for today's visit. LPA learned that Licensee, Evelyn Samson is no longer the Administrator for this facility. This inspection will focus on the infection control procedures this facility.

This facility is a single-story home with 6 bedrooms: 2 bedroom for staff and 4 bedroom for clients. There are currently 4 clients residing in this facility. At the time of the inspection 3 of 4 clients were attending day program. In the event of an outbreak, the clients are able to maintain distancing in each room. The facility operates with 24 live-in hour staffing that provide care and supervision.

At the entrance of the home, there is a table with sanitizer, disposable mask available for visitors. There was also a Hiro sanitizing mister to remove bacteria from clothing items and air in the common area for clients. Visitors are asked to sign in, take temperature and complete screening questions. There are separate screening sheets for staff and clients. Clients temperatures are checked daily and logged. Current Provider Information Notifications regarding COVID are stored in a binder along with instructions on how to don and doff mask for staff. Vaccination records for cleints and staff are stored in perspective folders and easily accessible. If clients or staff become symptomatic there are spare COVID test available. Results of the test are documented in a binder.

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SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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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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: SAMSON HOME CARE II
FACILITY NUMBER: 486801797
VISIT DATE: 11/28/2022
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Continued from 809

Bathrooms were stocked with hand washing supplies. Signs were posted in the bathroom to promote hand washing. The home was a comfortable temperature, clean and was observed to be in good repair. Fire extinguishers were charged, last serviced on 12/20/2021. All exits and walkways were found to be unobstructed and were free of debris. Smoke and carbon monoxide detectors were tested and found to be operational. LPA observed at least a 30 day supply personal protective equipment.

Licensee to submit the following forms in order to change Administrators: LIC 500, LIC 501, Copy of Administrator Certificate, LIC 215, Copy of Photo I.D and LIC 308

No deficiencies cited during visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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