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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 11:56:47 AM

Document Has Been Signed on 01/30/2023 11:56 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Joanne Samson, back-up administratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Samson Home Care 1 and met with Joanne Samson, back-up administrator. The purpose of this visit is to conduct a Case Management - Incident inspection.

The Department of Social Services, Community Care Licensing, Santa Rosa Regional Office received an incident report from Samson Home Care 1 submitted on 09/15/2022 regarding Client (C1). According to the report, the incident occurred on 09/14/2022 at C1's Day Program/School and police officers were contacted. LPA reviewed C1's file and discussed the current plan for C1 with Joanne.

LPA requested copies of C1's LIC602, IPP, and IEP to be submitted to CCL by 02/06/2023


**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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