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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803970
Report Date: 09/12/2023
Date Signed: 09/12/2023 05:16:02 PM

Document Has Been Signed on 09/12/2023 05:16 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:JESSIE'S PLACE, LLCFACILITY NUMBER:
486803970
ADMINISTRATOR:MURPHY, TINIKAFACILITY TYPE:
735
ADDRESS:122 CALIFORNIA ST.TELEPHONE:
(707) 731-1715
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 2CENSUS: 0DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 AM
MET WITH:Tinika Murphy, AdministratorTIME COMPLETED:
06:00 PM
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On 8/08/2023 Licensing Program Analyst, (LPA) Carol Fowler attempted to conducted an unannounced visit for the purpose of Annual Required 1 year.

Licensing Program Analysts (LPA) Carol Fowler conducted an announced Annual Required – 1 yr. required visit for this facility and was greeted by Licensee, Tinika Murphy. The facility currently has 0 clients in care but Licensee is in the process of becoming vendorized through North Bay Regional Center. Licensee will be notifying CCLD of vendorizing status and admission of clients once completed.

LPA toured the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last serviced on 8/3/2023 at the time of visit. Both smoke detectors and carbon monoxide detectors were tested found to be functioning. A storage shed located in the backyard containing yard supplies was found to be locked and secured.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins and cleaning supplies are stored in locked cabinets in the facility kitchen and storage room. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Medications and records will be located in secured cabinets located in facility office. Water at faucets accessible to clients measured 118.2 degrees F which is within Title 22 Regulation between 105 and 120 degrees F.

Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Administrator Certificate for Tinika N Murphy, #6056489735, expires on 11/02/2024.
Continue on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JESSIE'S PLACE, LLC
FACILITY NUMBER: 486803970
VISIT DATE: 09/12/2023
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Continue from LIC809

LPA requested the following documents be sent to CCL by COB 9/26/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

No deficiencies cited during today's visit. A copy of this report provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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