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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803361
Report Date: 01/30/2023
Date Signed: 01/30/2023 11:55:41 AM

Document Has Been Signed on 01/30/2023 11:55 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAMSON HOME CARE 1FACILITY NUMBER:
486803361
ADMINISTRATOR:SAMSON, EVELYN M.FACILITY TYPE:
735
ADDRESS:3122 SAN ANTONIO COURTTELEPHONE:
(707) 421-2394
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Joanne Samson, back-up administratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Joanne Samson, back-up administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature. Facility has a COVID-19 screening station. Designated staff have current CPR/first aid certifications in file. Fire extinguisher was charged and serviced 07/25/2022. The facility has an ample supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. The facility has submitted their Infection Control Plan to the California Department of Social Services, Community Care Licensing. During this visit, LPA verified staff COVID-19 vaccination records. All staff wore face masks during this visit.
LPA requested the following updated forms to be submitted to Community Care Licensing by 02/28/2023:
    · 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
    · LIC 610D Emergency Disaster Plan
    · LIC 9020 Register of Facility Residents
    · Copy of current Administrator's Certificate
    · Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

LPA requested forms needed to update the facility Administrator to Joanne Samson:
· LIC215, LIC500, LIC308, LIC501, copy of Administrator certificate

Exit interview conducted with Back-up Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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