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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804229
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:20:46 PM

Document Has Been Signed on 09/04/2024 03:20 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAN LORENZO HOMEFACILITY NUMBER:
486804229
ADMINISTRATOR/
DIRECTOR:		CUNNINGHAM, IRENEFACILITY TYPE:
735
ADDRESS:601 SAN LORENZO STREETTELEPHONE:
(707) 330-9314
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Irene Cunningham & Richard Cunningham, ApplicantsTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst(LPA) Hansen arrived unannounced to conduct a Pre-Licensing Inspection of this Adult Residential Facility and was greeted by Applicant Irene Cunningham. Applicant Richard Cunningham arrived shortly after. This pre-licensing inspection is being conducted due to a change of ownership. Irene Cunningham will be the facility's Administrator. There are currently 4 clients in care although all were at Day Programs during time of visit.

Facility has received a fire clearance approval from the local fire department- effective 4/29/24, for two (2) ambulatory clients and two (2) nonambulatory clients. Fire extinguishers, two (2) were serviced, and tagged, as required. Facility has six (6) smoke alarms and four (4) carbon monoxide detectors all tested and in working order. Each client room had a working carbon monoxide detector. Facility has a required infection control plan. Facility has required emergency disaster plan.

LPA and applicants conducted a tour and inspection of the indoor and outdoor portions of the facility. The facility consists of a single story residence with a total of 3 bedrooms for clients & 1 bathroom, office-staff room, laundry room attached to the garage, kitchen, dining room, living room, laundry room and storage room. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. LPA observed adequate supply of both perishable and non-perishable food sufficient for the 4 clients in care. There was an emergency food supply, including water in case of a disaster and/or facility emergency. Facility had a first aid kit, including the first aid guidebook. There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in various designated drawer and cabinets in kitchen.

Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAN LORENZO HOME
FACILITY NUMBER: 486804229
VISIT DATE: 09/04/2024
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Continued from LIC 809

Hot water temperature was checked at 106 degrees Fahrenheit. Facility has a backyard that includes a patio table with chairs. Medications are stored in a locked medication cabinet in the dining room and in the locked office. Toxins are secured in a lock cabinet located in the garage and not accessible to clients. There is a sufficient amount of hygiene products and linens for clients in care. Hallways are equipped with night lights for accessibility and client bedrooms have appropriate furnishings. Licensee applicant has posted hard copies of appropriate staffing records, program operation documentation and emergency disaster information on site. The facility has all appropriate public documentation and personal rights information posted in common spaces and hallways within the facility. P & I monies were documented, secure and not commingled. Disaster drills are conducted bi-monthly with the last being 8/3/2024.

Administrator Certificate for Irene Cunningham #7035956735 expires 12/4/2024.

Component III orientation was completed today, 9/4/2024, with applicants Irene Cunningham and Richard Cunningham.



Pre-Licensing is complete and this facility has no apparent health hazards and/or concerns observed during this inspection. The LPA will send a copy of the report to the Application Unit Analyst; The Application Unit Analyst will notify the applicant of the status of the application.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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