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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804177
Report Date: 03/07/2024
Date Signed: 03/07/2024 12:50:56 PM

Document Has Been Signed on 03/07/2024 12:50 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:Q & R RESIDENTIAL FACILITY LLCFACILITY NUMBER:
486804177
ADMINISTRATOR:PEARSON, ROSHAWNFACILITY TYPE:
735
ADDRESS:2707 WHITE ALDER CTTELEPHONE:
(707) 344-0344
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 0DATE:
03/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Roshawn Pearson, AdminTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a pre-licensing inspection and was greeted by Roshawn Pearson, Administrator.

At approximately 10:30am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature.

Facility is a two story residence with four bedrooms upstairs, including master bedroom with full bathroom, one bedroom downstairs and two full bathrooms, dining room, family room, living room, and a large backyard. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Water temperature read at 108 degrees F which is within regulation of 105 & 120 degrees F.

Facility has sufficient items used for cooking and eating. Facility has a locked closet in the hallway with two [2] locking cabinets used for centrally stored medications. Cleaning supplies and toxins are locked in a cabinet the garage. Facility has areas inside and outside for visiting and activities.

Facility received an approved fire clearance dated August 1, 2023 that allows for up to five [5] ambulatory residents. LPA observed fire extinguishers missing service tags. Administrator advised that fire extinguishers were last inspected when fire clearance was granted. Admin to send pictures of tags once received or correspondence from Fairfield Fire Department indicating that the fire extinguishers were serviced at time of fire clearance inspection and no longer require tags indicating service. Roshawn Pearson Administrator Certificate 6063000735 expires 2/2/2025.


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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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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: Q & R RESIDENTIAL FACILITY LLC
FACILITY NUMBER: 486804177
VISIT DATE: 03/07/2024
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LPA and Administrator observed broken panel on left hand side of main living room window blinds as well as on blinds in upstairs room #4. LPA observed fireplace not screened in living room. Admin advised that the fireplace is a gas fireplace that was disconnected by removing key plug in November 2023 and is no longer functional, no flue present. LPA observed partially missing backsplash behind kitchen range. Admin to repair/cover and send pictures of repair/cover.

LPA observed CCL CAB facility report but missing required posters. Admin to send pictures of required posters to CCL once posted in a conspicuous place.

The following items to be corrected and or obtained prior to LPA submission of facility's application for approval:
  • kitchen backsplash
  • blinds in main living room and bedroom #4
  • posters hung in a conspicuous place
  • email from Fairfield Fire Dept or pictures of tagged and current fire extinguishers


Once acceptable photographic proof is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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