<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803260
Report Date: 07/22/2022
Date Signed: 07/22/2022 10:03:31 AM

Document Has Been Signed on 07/22/2022 10:03 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: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:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Ralph Gause (Licensee)TIME COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year Inspection and met with Ralph Gause, Licensee. Current the facility does not have any residents in care.

LPA/Licensee toured the facility inside and outside. LPA/Licensee observed potential resident rooms are currently being utilized for a different purpose. Per Licensee, they are leaving in the facility due to their home is under construction and will be ready to move-in tentatively by the end of the year then the facility will be ready to be vendor by North Bay Regional Center. LPA /Licensee observed items within the interior and exterior of the home that would need to be removed prior to the admission of clients. Licensee agreed to notify CCL prior of admission of clients. 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. Fire extinguisher was last charged December, 2021 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 obstacles and debris. Facility Mitigation Plan was submitted and approved by 9/23/21. Per Licensee, they have not submitted their Infection Control Plan yet because they don't have any clients, LPA discussed with Licensee the importance of having an infection control plan in place and ready when clients move-in, LPA also will provide LIC9282 form to Licensee to fill out and submit to CCL.

LPA requested copies of the following documents to be submitted by 7/29/22: Designation of Administrative Responsibility (LIC308).

No deficiencies were cited during todays visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1