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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801797
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:28:42 PM

Document Has Been Signed on 04/03/2023 02:28 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:
04/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Evelyn Samson, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management inspection. LPA was met by on-call staff (S1), who was here with one resident. There are currently 4 residing in this facility. The other 3 residents were at Day Program. The Co-Administrator, Evelyn Samson, arrived shortly.

LPA toured the facility with S1 and found the facility to be clean and comfortable.
This facility is a single-story home with 6 bedrooms: 2 bedroom for staff and 4 bedroom for clients. There is also a storage building out in the back, where miscellaneous items were properly locked and stored. Facility showed LPA monthly room/medication/smoke detector logs.

LPA requested documents.

At the time of inspection there were no deficiencies found. No citations issued
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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