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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890073
Report Date: 07/10/2023
Date Signed: 07/11/2023 01:25:54 PM

Document Has Been Signed on 07/11/2023 01:25 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:SHIR-LEE'S CARE HOMEFACILITY NUMBER:
486890073
ADMINISTRATOR:LOFTON, ANGELAFACILITY TYPE:
735
ADDRESS:2548 TENNESSEE STREETTELEPHONE:
(707) 648-2964
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 4CENSUS: 2DATE:
07/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angela loftonTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Angela Lofton, Licensee/Administrator. There is currently 2 clients in care.

LPA toured facility and grounds with administrator and observed the home to be at a comfortable temperature with all exits free from obstruction. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured 115 degrees F which are within the required regulation range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Facility has emergency packs available in the office. Medications were centrally stored and locked in medication file closet along with client files.

Fire extinguishers were last serviced 7/6//2023. Smoke/Carbon Monoxide detectors were operational. Most recent fire/disaster drill was conducted July 2023

Staff and Client files were reviewed. Staff have required First Aid and CPR certificates that expire 10/7/2024. Administrator Certificate for Administrator Angela Lofton is active and LPA verified they submitted a request for renewal and are waiting for the new certificate to be processed.


Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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: SHIR-LEE'S CARE HOME
FACILITY NUMBER: 486890073
VISIT DATE: 07/10/2023
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LPA requested the following updated records to be submitted to Community Care Licensing by 8/10/2023

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources & Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
Infection Control Plan ( if changes)
Copy of Lease Agreement
Facility to send in update of small backyard ramp plan.

Exit interview conducted with Angela Lofton, No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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