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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803507
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:41:07 PM

Document Has Been Signed on 02/16/2023 12:41 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:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Caregiver, Dinia JulianTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at St. Jude Residential Facility LLC for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Caregiver, Dinia Julian, and was granted access into the home. Caregiver did not do COVID-19 check-in with the LPA (See LIC 9102-Technical Assistance). Administrator, Rose Devera arrived 20 minutes later.

LPA and Caregiver toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on November 2022 at the time of the inspection. Smoke detectors and Carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in clients bathroom measured at 113 degrees in 2 out of 2 clients bathrooms and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. First aid kit was inspected and found to be appropriate 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. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE which is stored in the staff room. Staff at the facility have been N95 Fit tested.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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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: 02/16/2023
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview and a copy of this report was given to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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