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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804255
Report Date: 07/18/2024
Date Signed: 07/18/2024 01:24:18 PM

Document Has Been Signed on 07/18/2024 01:24 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:ST. JUDE CARE HOME 111FACILITY NUMBER:
486804255
ADMINISTRATOR/
DIRECTOR:
DEVERA, ROSE MARIE B.FACILITY TYPE:
735
ADDRESS:1028 ARMSBY WAYTELEPHONE:
(707) 290-0614
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 0DATE:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Rose Marie B. Devera, Licensee/ApplicantTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 9:20 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a pre-licensing inspection and was greeted by Licensee/Applicant, Rose Marie B. Devera. This pre-licensing inspection is being conducted for an initial licensing of an Adult Residential Facility (ARF). Fire Clearance has been approved for 4 non-ambulatory clients. Licensee/Applicant is currently in partnership with North Bay Regional Center (NBRC) and plans for client placement upon issuance of license.

At approximately 9:30 AM, LPA initiated a tour of the facility and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with the required non-slip mats, but were missing grab bars. Licensee/Applicant had them installed before the conclusion of today's inspection. LPA observed a supply of clean linens, hygiene products, incontinent care products, and paper products available to clients. Hallways are equipped with night lights and clients' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. All client bedrooms are located on the second floor and each is equipped with an intercom which allows client communication to a central receiver located downstairs in the dining area.

There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the kitchen sink. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. However, LPA observed toxic chemicals in the unlocked garage, which Licensee/Applicant removed and secured immediately. Facility has at least two days of perishable foods, one week of non-perishable foods, and an emergency water supply. LPA observed a sample menu posted in the common area to indicate a healthy and balanced set of meals for clients in care.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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: ST. JUDE CARE HOME 111
FACILITY NUMBER: 486804255
VISIT DATE: 07/18/2024
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...continued from LIC809...

The facility has a working landline telephone on site with internet services and a laptop for client use. Facility has a designated area with locked cabinets for centrally stored medications and client, staff, and facility files. LPA observed the facility's infection control plan, first aid kits, PPE, other emergency supplies, activity schedule, and games available for client use.

Facility has two fire extinguishers, which were last inspected May 2024 and are fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection. LPA observed no evacuation chair present in facility. LPA informed Licensee/Applicant that "an evacuation chair at each stairwell in a residential facility serving adults" is required per Health and Safety Code, Section 1565(f)(1). Licensee/Applicant purchased one immediately and a receipt was provided to LPA during visit.

Licensee/Applicant has posted hard copies of the required program operation documentation, emergency disaster plan and maps, personal rights information, and reporting posters in facility communal areas. LPA informed Licensee/Applicant that visiting hours shall be posted as well. The facility currently has Licensee/Applicant and one staff member associated to facility and will begin hiring additional staff once NBRC approves the facility's vendor application. Licensee has been informed of association and staff transfer process.

The backyard features paved walkways, a lawn/dirt area, and patio with a shaded seating for client outdoor use. LPA advised Licensee/Applicant to purchase a larger shade for the seating area. The facility is working with a contractor who will be installing turf in the lawn/dirt areas. Licensee/Applicant states, facility will acquire additional recreational items for client use upon admission. Windows, screens, and blinds are all found to be in good repair and facility exits are clearly identified.

Licensee/Applicant provided LPA with a copy of the facility's lease agreement, proof of liability insurance, and a professional facility sketch which accurately reflects the floor plan.

Component III orientation was conducted with the Licensee Applicant at facility. Licensee/Applicant conveyed knowledge and understanding of Title 22 regulations. 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.

Exit interview conducted with Licensee, whose signature on this document confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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