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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803361
Report Date: 12/12/2023
Date Signed: 03/01/2024 11:53:02 AM

Document Has Been Signed on 03/01/2024 11:53 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:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Joannalyn Agbayani, Co-AdministratorTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Joannalyn Agbayani,co- administrator. There are currently 4 residents at the facility. There were 2 staff on site at the time of inspection. All four residents were attending Day Programs.

LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature of 74 F. Water temperature measured 112 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 07/17/2023. Carbon monoxide detector and smoke detectors were operational. Last fire drill was on 12/5/2023 for all shifts. The facility has an ample supply of perishable and non-perishable foods as required by Title 22.

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.

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 1
FACILITY NUMBER: 486803361
VISIT DATE: 12/12/2023
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Continued from 809....

REPORT HAS BEEN AMENDED


LPA requested forms needed to update the facility Administrator to Joannalyn Agbayani.

No deficiencies were 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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