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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803260
Report Date: 09/23/2021
Date Signed: 09/23/2021 05:28:23 PM

Document Has Been Signed on 09/23/2021 05:28 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:RYAN HOUSEFACILITY NUMBER:
496803260
ADMINISTRATOR:GAUSE, LIYAN ZHANGFACILITY TYPE:
735
ADDRESS:4033 PRINCETON DRIVETELEPHONE:
(707) 578-5707
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 3CENSUS: 0DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Licensee, Ralph GauseTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required 1 Year Inspection and met with Ralph Gause, Licensee. Current facility census is zero.

At 5:00 PM, the facility was toured. There are currently no residents in care. Potential resident rooms are currently being utilized. LPA observed items within the interior and exterior of the home that would need to be removed prior to the admission of clients. Water temperature measured 111.5 degrees which is within regulation. All medication and client/personnel records are to be stored in the locked hall closet. Cleaners, toxins, and items that can pose a danger will be stored in a locked cabinet in the garage. Licensee does not plan to handle client's cash resources.

Fire extinguisher was last charged December, 2020 and the facility continues to have fire inspections. The smoke detectors are operational. A first aid kit is kept on site. All exits are accessible and free of debris.

LPA received COVID mitigation plan during visit.

LPA requested the following documents during visit: LIC 308, LIC 610D, LIC 500, and admin certificate.


No deficiencies were cited during todays visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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