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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803417
Report Date: 03/28/2023
Date Signed: 03/28/2023 09:47:41 AM

Document Has Been Signed on 03/28/2023 09:47 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: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: 4DATE:
03/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dinah BelandresTIME COMPLETED:
10:00 AM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on two incidents involving a client in care who has recently come in contact with law enforcement and has not been following the house rules in regards to curfews, communicating with staff and substance abuse. LPA spoke with staff and reviewed records. A phone conference was held with Administrator, Rose Devera. It was determined that appropriate action has been taken by facility management and that meetings are scheduled with NBRC and substance abuse program staff to address the future needs of the client and supervision of the client has been enriched.


No citations issued today.
Report left.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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