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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109865
Report Date: 05/12/2023
Date Signed: 05/12/2023 10:57:12 AM

Document Has Been Signed on 05/12/2023 10:57 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: 5DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Jeff LaDow (Licensee)TIME COMPLETED:
11:12 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Jeff LaDow. At the time of visit, all clients were attending to Day Program.

Upon arrival, LPA confirmed with Licensee that they are following current Covid19 and masks guidance. LPA/Licensee initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 118.8 and 115.7 which are within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet in the garage. Medications are centrally stored in locked boxes. Fire extinguishers were last inspected April 2023. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 4/25/23. Facility does have a current activity calendar. Required postings were observed. Emergency supplies were observed including flashlights and water. First aid kit was fully stocked. Facility van was inspected and have 1st aid kit fully stocked and fire extinguisher service and charged.

LPA initiated a file review at 9:00 am. Five client and six staff files were reviewed. Clients records have updated care plans on file. First aid certificates for staff are current. Administrator Certificate for Jeff LaDow 6014982735, expires 4/12/2024. Medications and medication records were reviewed. Cash resources and documentation were reviewed.

LPA obtained updates of the following documents: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 (cash affidavit for clients) and LIC610D - Emergency Disaster Plan.

No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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