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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803361
Report Date: 01/03/2025
Date Signed: 01/03/2025 02:50:51 PM

Document Has Been Signed on 01/03/2025 02:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAMSON HOME CARE 1FACILITY NUMBER:
486803361
ADMINISTRATOR/
DIRECTOR:		SAMSON, EVELYN M.FACILITY TYPE:
735
ADDRESS:3122 SAN ANTONIO COURTTELEPHONE:
(707) 421-2394
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joannalyn Agbayani, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Joannalyn Agbayani, Designated Responsible Party. Licensee, Evelyn Samson was contacted via telephone, arrived at approximately 10:45 AM and was present for approximately 1 hour during facility tour. During such time, Licensee expressed the desire to appoint DRP as the facility Administrator permanently. LPA informed Licensee that a list of the required documentation by Licensing will be included in today's inspection report. Facility is an Adult Residential Facility with four (4) ambulatory clients in care, all of whom were away at Day Program during today's inspection. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 10:35 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. LPA advised DRP to ensure no towels are hanging in communal bathrooms and that trash cans in the bathrooms have lids on them to bring the facility into compliance with regulations. Clients' bedrooms were inspected and observed to have all of the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded area in the backyard with outdoor space for activities. LPA observed a locked storage shed in the backyard which contained mostly chemicals and tools. Additionally, LPA observed a deadbolt style lock on one of the two backyard gates and advised Licensee and DRP to replace it with a regulatory compliant latch lock. Both agreed to have it replaced immediately. LPA was informed that all clients have their own internet access devices and the facility has internet available to clients in care. The facility telephone was tested an operational during today's inspection.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAMSON HOME CARE 1
FACILITY NUMBER: 486803361
VISIT DATE: 01/03/2025
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Continued from LIC809...

Facility's fire extinguisher was observed charged and was last serviced July 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, with the most recent drill conducted September 2024. DRP states they will conduct a drill this week and submit proof to CCL. LPA observed facility's infection control plan and emergency disaster plan which was last updated June 2024. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. DRP states the facility does not have a backup generator.

At approximately 12:00 PM, LPA reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed have all the required paperwork and proof of current First Aid and CPR training. Four (4) of four (4) client files reviewed have all the required paperwork, except each was missing an Appraisal Needs and Services Plan signed and dated by the client or their responsible party, (see LIC809D). Staff coordinate medical and dental visits for the clients and take them to and from their appointments.

At approximately 1:15 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. LPA reviewed P&I monies and logs, which were organized, maintained, and stored in accordance with regulation.

Required Change of Administrator Documents:
  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAMSON HOME CARE 1
FACILITY NUMBER: 486803361
VISIT DATE: 01/03/2025
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  • Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • LIC610D - Emergency Disaster Plan (updated)
  • LIC400 - Affidavit Regarding Client Cash Resources (updated)
  • LIC402 - Surety Bond (updated)
  • Proof of Current Disaster Drill Conducted

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with DRP and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/03/2025 02:50 PM - It Cannot Be Edited


Created By: Julie Florio On 01/03/2025 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAMSON HOME CARE 1
FACILITY NUMBER: 486803361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 client files reviewed which had care plans that had not been signed by each clients or their responsible party, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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DRP agrees to submit proof of a signed and dated care plan by each client or their responsible party to CCL by POC due date 02/03/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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