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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803507
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:21:18 PM

Document Has Been Signed on 04/19/2022 04:21 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 RESIDENTIAL FACILITY LLCFACILITY NUMBER:
486803507
ADMINISTRATOR:DEVERA, ROSE MARIE B.FACILITY TYPE:
735
ADDRESS:932 BRETON DRIVETELEPHONE:
(707) 290-0614
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rose Devera, Licensee & Administrator TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Rose Devera, Licensee & Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.
LPA conducted a walk-through of the facility with staff. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors. LPA was screened for COVID-19 symptoms and temperature was taken. Staff have valid CPR/first aid certifications. Fire extinguisher was charged and serviced 11/24/2021. Staff have documented training from Solano County Public Health training on the following COVID-19 related subjects: infection prevention, symptoms, transmission, environmental cleaning to prevent COVID-19 and PPE use. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. The facility has designated visitation areas, provides virtual visits and phone calls for visitors to stay in contact with clients. Staff clean and disinfect the facility throughout the day. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and disposable gowns.

The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.
All staff wore masks during this visit.


LPA discussed the following requirements with Administrator:
· N-95 Fit testing (Cal/OSHA Requirement) for staff
· Verify & document vaccination records or a negative COVID test for indoor visitation.
Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ST. JUDE RESIDENTIAL FACILITY LLC
FACILITY NUMBER: 486803507
VISIT DATE: 04/19/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 5/9/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Rose Devera, Licensee & Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection


SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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