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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803970
Report Date: 08/18/2021
Date Signed: 08/18/2021 11:25:53 AM

Document Has Been Signed on 08/18/2021 11:25 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:JESSIE'S PLACE, LLCFACILITY NUMBER:
486803970
ADMINISTRATOR:MURPHY, TINIKAFACILITY TYPE:
735
ADDRESS:122 CALIFORNIA ST.TELEPHONE:
(707) 561-1206
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 2CENSUS: 0DATE:
08/18/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Tanika Murphey, Licensee/Administrator ApplicantTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Dominic Tobola arrived to this facility for the purpose of completing a pre-licensing evaluation. LPA was greeted by Licensee/Administrator Applicant Tanika Murphey and conducted a tour of the facility. The facility is a 2 bedroom, 2 bathroom, single story house. LPA toured the entire premise which was found to be clean and orderly. Fire extinguisher last inspected along with fire clearance on 4/21/2021. Smoke detectors tested and found to be in working order. Carbon monoxide detectors were located in the laundry room and found to be in working order. Licensee plans to install additional carbon monoxide detectors near client bedrooms for added safety measures. Medications, facility files and emergency supplies are stored in a secured office space. Toxins and cleaning supplies are secured in locked cabinets in the laundry room. Sharps and knives are secured in a locked cabinet in the kitchen.

LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 2 clients. There is a closet located in the hallway that holds extra linens.

Beds were made with appropriate linens. Furniture is appeared safe and adequate. Hot water temperature was measured between 119 and 125 degrees F which is not within regulation between 105 degrees F and 120 degrees F. However, each faucet accessible to clients is equipped with appropriate cautionary signage for hot water exceeding 125 degrees F. Licensee plans to keep water within regulation and maintain a water temperature log recorded on a weekly basis. There is a locked storage shed in the backyard that contains gardening and home supplies.

A fire clearance for this facility has been granted for 2 ambulatory clients. An emergency exit along the right side of the facility are unobstructed and equipped with self closing latches.
Component III orientation was conducted with the Licensee Applicant.

The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided to the Licensee via email. Signatures on file.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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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