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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803949
Report Date: 05/07/2021
Date Signed: 05/12/2021 10:26:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ST JOSEPH CARE HOMEFACILITY NUMBER:
486803949
ADMINISTRATOR:LIM, RAQUEL VICTORIAFACILITY TYPE:
740
ADDRESS:829 HARRIER DRIVETELEPHONE:
(510) 809-6912
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 5DATE:
05/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Victoria LimTIME COMPLETED:
06:45 PM
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Licensing Program Analyst (LPA) K. Walters conducted a pre-licensing inspection on 05/07/2021 virtually. Due to COVID – 19 precautions, a facility visit is not able to be conducted at this time. LPA met with applicant Victoria Lim who will be the Administrator once the facility is approved for licensure. Applicant stated firearms will not be stored or present at the facility. LPA virtually toured the facility with Victoria Lim.

The following items were reviewed during this subsequent pre-licensing inspection:
  • Facility was organized and free of obstructions.
  • Lockable cabinets for food storage, cups/utensils, medications, toxins, and knives.
  • Extra supply linens, towels, wash cloths, bedding, blankets.
  • Supply of cleaners and disinfectants.
  • LPA observed that the facility sketched matched the facility layout.
  • Auditory alarm was observed to be in working order.
  • Cleared/clean resident closets and bedrooms.
  • Personal items (including hygiene items/bottles) cleared from client bedrooms and closets.
  • Required furnishings for clients in all bedrooms.
  • 5 hardwired smoke detectors and 1 carbon monoxide detector; which applicant tested and LPA observed to be operational.
  • Night-lights in hallway leading to the bathroom and flashlights for emergency lighting.
  • The shed was locked and not accessible to residents in care.

Continued on 9099 C

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ST JOSEPH CARE HOME
FACILITY NUMBER: 486803949
VISIT DATE: 05/07/2021
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Continued from 9099

At the time of inspection the following items were observed to not be incompliance with Tittle 22 regulations. Modifications to be made by 5/11/21. Details were discussed with applicant and provided in writing:
  • LPA reviewed the personnel records. Records were incomplete. LPA is requesting modification be made prior to licensure of facility.
  • LPA is requesting modification to resident medication records.
  • LPA reviewed Admission Agreements. Admission Agreements need to be modified to be in compliance with tittle 22 regulations.
  • Complaint poster was not posted.

The Component III Orientation was completed. LPA reviewed and discussed items in the Component III Orientation with Applicant and Staff present during the the visit. Suisun City Fire Department approved the amended facility sketch on 05/4/21.

Pre-Licensing is COMPLETE. LPA will submit the pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

*Signatures on file. A copy of this report was provided to applicant.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2