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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109865
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:27:21 AM

Document Has Been Signed on 04/14/2022 10:27 AM - 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:STEPHEN'S HOUSEFACILITY NUMBER:
490109865
ADMINISTRATOR:LA DOW, JEFFFACILITY TYPE:
735
ADDRESS:2420 GARDNERTELEPHONE:
(707) 542-0506
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Stephanie Garcia (House Manager)TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with House Manager, Stephanie Garcia. Licensee, Jeff La Dow arrived later. LPA conducted a Risk Assessment at the facility with House Manager.

LPA/House Manager conducted a tour through the facility and observed facility was a comfortable temperature and passageways were free from obstructions. Facility has submitted and approved their mitigation plan on 7/27/21. Posters have been placed at entrance, and facility are allowing indoor visitations and has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored daily. However, facility is not consistently documenting results of daily screening. Facility has PPE supplies stored in the storage room. Facility has a 30-day supply of medication for clients. Clients do not typically wear masks inside the facility but have them available. Clients do however, wear masks while away from the facility. All staff had masks on during this visit, but they have not been N95 fit tested. Facility has a 100% rate of staff, clients are vaccinated and boosted. Facility has conducted staff training on infection control. Five out of six clients do attend to Day Program and facility provides games and other activities for entertainment. Client files were not available at the time of visit a technical violation was issued and Licensee agreed to maintain records at the facility for review.

Licensee will submit updated copies of the following documents by 4/21/22: Affidavit Client Cash Resources (LIC400), Designation of Responsibility (LIC308), Personnel Report (LIC500) and Surety Bond.

No deficiencies were cited during today's inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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