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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803417
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:45:41 PM

Document Has Been Signed on 01/23/2025 12:45 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/
DIRECTOR:		CONSTANTINO, BELANDRESFACILITY TYPE:
735
ADDRESS:2613 ELMHURST CIRCLETELEPHONE:
(707) 389-4631
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Constantino Belandres, Administrator and Rose Marie Devera, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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At 9:10 AM, Licensing Program Analyst (LPA), Robert Frank arrived unannounced at St. Jude Care Home II for the purpose of conducting a Required 1 year inspection. Upon arrival at the facility, LPA was greeted at the door by Caregiver (CG), Dinah Belandres, and was granted access into the facility. At 9:40 AM Administrator, Constantino Belandres returned to the facility from driving a client to their day program. At 9:45 AM Licensee, Rose Marie Devera arrived at the facility. One (1) of four (4) clients were present during the inspection.

At 9:45 AM, LPA, Administrator Belandres, Licensee Devera and CG Belandres toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 11/12/2024. Smoke and carbon monoxide detectors were found throughout the facility, tested and to be in working order. Facility conducts and records emergency disaster drills on a quarterly basis. The last disaster drill was conducted on 1/10/2025. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients was measured between 106.1 and 109.1 degrees F which is within Title 22 Regulations. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to clients in care. There was a supply of Linens, cleaners, hygiene products and paper products available for clients.

Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: ST. JUDE CARE HOME II
FACILITY NUMBER: 486803417
VISIT DATE: 01/23/2025
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...Continued from 809

All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. A tour of all clients bedrooms was conducted, and bedrooms inspected had lighting and appropriate furnishings. Facility has PPE which is stored in the hallway closet closest to the kitchen. LPA conducted a review of five (5) of five (5) staff files and found all staff to have 1st Aid & CPR certification and annual training on file. LPA reviewed four (4) of four (4) client records and found all required documentation including an updated Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. LPA conducted a spot medication count for four (4) of four (4) clients and were found to be in order along with properly documented centrally stored medication and administration records. LPA reviewed Personal and incidental (P&I) monies for four (4) clients. All monies matched P&I logs and were under the maximum value as listed on the LIC 400 Affidavit regarding client cash resources.

Administrator, Constantino Belandres's Administrator Certification 7024494735 is current through 9/2025,
Administrator, Dinah Belandres's Administrator Certification 7032809740 is current through 7/2025.

LPA requested the following documents to be sent CCLD by no later than DOB 2/23/2025:

LIC 308- Designation of Responsibility
LIC 402-Surety Bond - Updated
LIC 309- Administrative Organization
LIC 610D- Emergency Disaster Plan

No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to Administrator and Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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