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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803417
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:04:39 PM

Document Has Been Signed on 01/13/2023 02:04 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:ST. JUDE CARE HOME IIFACILITY NUMBER:
486803417
ADMINISTRATOR:DEVERA, ROSEFACILITY TYPE:
735
ADDRESS:2613 ELMHURST CIRCLETELEPHONE:
(707) 389-4631
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
01/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Caregiver, Diana BinahTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at St. Jude Care Home II for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Caregiver, Diana Binah, and was granted access into the facility.

On January 10, 2023, LPA conducted a Required 1 year inspection and was notified by the Administrator that the electricity/power went out and then went back on later in the evening that same day. LPA is conducting this inspection to ensure that lights and power is on and operating normally. During the Case Management-Other inspection, LPA observed the lights and power being on in all areas of the facility including the refrigerator and freezer.

No deficiencies were observed or cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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