<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803417
Report Date: 01/22/2024
Date Signed: 01/22/2024 01:15:24 PM

Document Has Been Signed on 01/22/2024 01:15 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: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:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dinah BelandresTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Parks arrived on Monday January 22, 2024 to conduct the unannounced annual inspection.

LPA met with Administrator Dinah and explained the purpose of the visit.

During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed 4 client files and 2 staff files. All client contained the required paperwork. All staff files contained the required paperwork and training.

LPA and Administrator toured facility together to ensure the health and safety of clients in care. Areas toured included common area, bathrooms, bedrooms, kitchen and backyard. Facility has a full supply of PPE. Cleaning products are kept locked and inaccessible to clients. Medications are kept locked in dining room. Facility is current on fire drills. First Aid kit is fully stocked. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA requested the facility send an updated LIC500 to the Regional Office.

No deficiencies cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1