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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803507
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:03:38 PM

Document Has Been Signed on 04/18/2024 12:03 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 RESIDENTIAL FACILITY LLCFACILITY NUMBER:
486803507
ADMINISTRATOR/
DIRECTOR:
DEVERA, ROSE MARIE B.FACILITY TYPE:
735
ADDRESS:932 BRETON DRIVETELEPHONE:
(707) 290-0614
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Rose DeveraTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has four private resident rooms and one staff room. One resident room has a private half bathroom. There is one full common bathroom. The common areas are on the right of the facility. There is a wood deck and ramps in the backyard. The ramp and decks are well maintained. LPA toured the resident rooms and common areas and did not observe any issues.

Two resident and staff files were reviewed.

A couple of topics were discussed

The following shall be updated and submitted to Community Care Licensing Division by May 3, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule
-plan for incidental and medical care for residents
-copy of current lease agreement.



no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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