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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803507
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:45:36 AM

Document Has Been Signed on 05/02/2024 11:45 AM - 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/
DIRECTOR:		DEVERA, ROSE MARIE B.FACILITY TYPE:
735
ADDRESS:932 BRETON DRIVETELEPHONE:
(707) 290-0614
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Rose Devera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 5/2/2024, Licensing Program Analyst, Dominic Tobola arrive unannounced for the purpose of following up on previous Annual Inspection fire clearance inquiry. The facility is currently fire cleared for 1 non-ambulatory client. LPA and Administrator discussed an updated fire clearance and Administrator will be submitting a new LIC200 form for fire inspection. Based on current census and client ambulatory status, the facility is in compliance. LPA to follow up with new fire inspection once submitted.

No deficiencies cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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