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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804262
Report Date: 01/02/2025
Date Signed: 01/02/2025 02:49:18 PM

Document Has Been Signed on 01/02/2025 02:49 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:YB RESIDENTIAL FACILITYFACILITY NUMBER:
486804262
ADMINISTRATOR/
DIRECTOR:		YOUNGBLOOD, RACHELLEFACILITY TYPE:
735
ADDRESS:315 FLAGSTONE CIRCLETELEPHONE:
(510) 499-5015
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 3CENSUS: 0DATE:
01/02/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Rachelle Youngblood, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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On 01/02/2025 Licensing Program Analyst (LPA) Jill Nakagawa conducted an inspection for the purpose of completing a pre-licensing evaluation.LPA was greeted by Licensee/Administrator Rachelle Youngblood who conducted a tour of the facility. The facility is a 3 bedroom 2.5 bathroom two-story house. Fire clearance is for three (3) ambulatory clients. LPA toured the entire premises which was found to be clean and orderly.

There were two (2) fire extinguishers last inspected 11/15/2024; mounted and charged. Smoke detectors tested and found to be in working order. Carbon monoxide detectors were located in the each hallway and found to be in working order. Medications, facility files, emergency supplies and sharps are stored in a locked closet near the kitchen. Toxins and cleaning supplies are secured in locked cabinets inside the garage.

LPA observed at least a 7 day supply of non-perishable food necessary for 3 clients. Non-perishables will be supplied prior to arrival of first client. There was an ample supply of dishes and cooking supplies.

Beds were made with appropriate linens. Furniture appeared safe and adequate. Hot water temperature was measured within regulation between 105 degrees F and 120 degrees F. There are cabinets located in the resident hallway that holds extra linens and towels.

Required postings such as Complaint poster, Rights to resident councils, client's rights are posted in the facility. Resident and staff records and other documentation will be secured in the medication closet.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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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: YB RESIDENTIAL FACILITY
FACILITY NUMBER: 486804262
VISIT DATE: 01/02/2025
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Component III orientation was conducted with the Licensee/Administrator Applicant.

The pre-licensing evaluation has been completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report will be forwarded to the Centralized Application Unit for continued processing.

This report was reviewed with applicant and a copy was provided.

No deficiencies were cited during today's visit.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
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