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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801797
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:01:23 PM

Document Has Been Signed on 12/12/2023 03:01 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:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Joannalyn Agbayani, Co-AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at the Adult Residential Facility (ARF) unannounced to conduct Required- 1 Year visit. Administrator, Joannalyn Agbayani granted LPA entrance into the facility. There was one staff member and no clients at the initial time of inspection. There are 4 residents, who were all attending Day Programs.

At the entrance of the home, there is a table with sanitizer and a Hiro sanitizing mister to remove bacteria from clothing items and air in the common area for clients. This facility is a single-story home with 6 bedrooms: 2 bedrooms for staff and 4 bedrooms for residents.

LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature of 68 F. Water temperature measured 116 F. Bathrooms had soap and paper towels, non-skid mats for showers and baths. Designated staff have current first aid certifications in file. Fire extinguisher was charged and serviced 12/07/2023. Carbon monoxide detector and smoke detectors were operational. Last fire drill was on 11/27/2023 for all shifts. The facility has an ample supply of perishable and non-perishable foods as required by Title 22.


Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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: SAMSON HOME CARE II
FACILITY NUMBER: 486801797
VISIT DATE: 12/12/2023
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LPA requested the following updated forms to be submitted to Community Care Licensing by 01/01/2024:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)· Copy of surety bond
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

The facility was decorated for the holidays and a Xmas Tree sparkled in the living room.

There were no deficiencies found at the time of inspection. NO CITATIONS ISSUED.

Exit interview conducted with Joannalyn Agbayani, whose signature on this document confirms receipt.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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