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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890081
Report Date: 02/09/2022
Date Signed: 02/10/2022 04:41:08 PM

Document Has Been Signed on 02/10/2022 04:41 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:GOOD SAMARITAN CARE HOME LLCFACILITY NUMBER:
486890081
ADMINISTRATOR:SKILLMAN, TROYFACILITY TYPE:
735
ADDRESS:364 PEPPER DRIVETELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
02/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rosie Skillman, Licensee/AdministratorTIME COMPLETED:
06:30 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted a pre-licensing inspection on 02/09/2022.
LPA met with applicant Rosie Skillman, who will be the Administrator once the facility is approved for licensure. Additionally Judy Johnson, administrator assistant was present. The facility received a fire clearance approval on 1/9/2022 from the Vallejo Fire Department for total capacity of 6 ambulatory clients. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station
· Lockable separate cabinets for medications, toxins/cleaners, and knives.
· All exits were unobstructed
· 4 smoke detectors and 1 carbon monoxide detectors, which were tested and observed operational.
· 1 charged Fire Extinguisher
· Supply of linens, paper products, and hygiene supplies available
· Complete first Aid kit, night-lights, and flashlights for emergency lighting
· Required furnishings in all 4 bedrooms
· Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster).
· The water temperature was tested during inspection an within the required 105 to 120 degrees F

The Component III Orientation was completed.

Pre-licensing is complete with no corrections needed. LPA will review file and process application for licensure.

No citations issued

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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