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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804177
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:46:47 PM

Document Has Been Signed on 03/13/2025 02:46 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/
DIRECTOR:		PEARSON, ROSHAWNFACILITY TYPE:
735
ADDRESS:2707 WHITE ALDER CTTELEPHONE:
(707) 344-0344
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 4DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Deajah Jefferson- CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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At approximately 9:30AM Licensing Program Analyst (LPA) Stevenson arrived to conduct a Required - 1 Year Inspection. A phone call with licensee Roshawn Pearson was made who reports, Deajah Jefferson, who has designation of facility responsibility, was available during inspection. 1 of 4 clients was home, 2 of 4 were away at day programs, and 1 of 4 is in temporary inpatient rehabilitation.

At approximately 10:00AM LPA and caregiver Jefferson toured the facility. Facility has an infection control plan as required. Fire clearance approval is for four (5) ambulatory: licensee Pearson states that "although fire clearance is for 5 ambulatory clients, North Bay Regional Center has only cleared the home to have 4 clients" Licensee would like to convert downstairs staff office into a bedroom and was asked to submit a new facility sketch to Community Care Licensing with detailed use for each room and garage, along with a new Application for a Community Care Facility or Residential Care Facility for the Elderly License (LIC200) indicating the change of room use for the downstairs staff office.

Facility was found be clean and spacious. Facility was found to be cool with thermostat set at 66 degrees and technical advice given that home should be between 68 degrees and 85 degrees with clients in care. Facets available to clients were found to be within 105 to 120 degrees as required by title 22 regulations.
All exits were cleared and free of obstruction. Two Fire extinguishers were observed to be fully charged and last inspected March 2024. Combination smoke and carbon monoxide detectors throughout the home were found to be functional.
P&I monies were accounted for and not co-mingled
LPA reviewed four (4) resident files. Four (4) of (4) resident files observed to be missing TB testing results.
LPA reviewed five (5) staff files. All staff had required criminal record clearance. All staff had required training.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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Document Has Been Signed on 03/13/2025 02:46 PM - It Cannot Be Edited


Created By: Star Stevenson On 03/13/2025 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: Q & R RESIDENTIAL FACILITY LLC
FACILITY NUMBER: 486804177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and phone interview with licensee, the licensee did not comply with the section cited above in 4 out of 4 client records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee to submit to Community Care Licensing by 03/14/2025 a letter by email or fax indicating he understands the requirement to have the results of TB testing for clients in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


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: 03/13/2025
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Continued from LIC809
All medications were locked up and inaccessible to residents in care. All toxins were locked up and inaccessible to residents in care. There is sufficient lighting in the hallways, bathrooms, and common areas, as well as client rooms. Food supply was sufficient There was sufficient furnishings for clients in care.

LPA is requesting the following forms be updated and submitted by 04/13/2025
· LIC 500 -Personnel Report
· LIC 610 - Disaster Plan
· LIC 308 - Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with caregiver Deahah Jefferson. Appeal rights provided for the licensee Administrator
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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