496804254-9-13-2024-21-AS-DALO-D93RWN-20240913132325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804254
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:23:31 PM

Document Has Been Signed on 09/13/2024 01:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SAINT JEANNE CARE HOME, LLC		FACILITY NUMBER:	496804254
ADMINISTRATOR:	TAMBAUAN-HAGAN, CATHERINE		FACILITY TYPE:	740
ADDRESS:	1923 ROGERS WAY		TELEPHONE:	(707) 315-1733
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	5	CENSUS: 0	DATE:	09/13/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Denice Tambauan-Applicant		TIME COMPLETED:	01:40 PM

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), Alviso conducted a pre-licensing inspection, at approximately 9:20am on 9/13/24, and met with Applicant Denice Tambauan. Catherine Tambauan-Hagan was also in attendance, and is planning to be the facility Administrator. LPA conducted a component III orientation with Applicant Denice Tambauan and Catherine Tambauan-Hagan, on 9/13/24. Applicant has an approved fire clearance for five (5) ambulatory residents- effective 6/6/24. There is a carbon monoxide detector in the facility, which is also a smoke alarm. All required rooms have a smoke alarm. There are three (3) resident rooms, two (2) are shared rooms (2 to a room), and one (1) is a private room (for 1 only). Per fire clearance approval of ambulatory residents only, the hospice waiver request for three (3) can't be approved. Residents on hospice must be residing in a non-ambulatory fire cleared room. Applicant states that she wants to request another fire clearance inspection to be completed as they are questioning the approval; The facility has required ramps, one in the front of the home, and the other in the backyard, which leads to a gate out to the front of the home. Applicant stated that fire inspector stated to them, every room had to have a direct exit to the outside, but applicant stated they believe this was a mistake, other facilities have non-ambulatory and don't have direct exit out. LPA stated to the applicant, they may resubmit the facility sketches, include all outside buildings that were not part of the fire clearance inspection, though they are on the sketch. LPA will send out a fire clearance request with sketches, and explain capacity requested, to the local fire department for re-inspection. Applicant agreed to submit required documents for the fire clearance reinspection. Applicant has submitted a required emergency disaster plan, and a required infection control plan. The LPA toured the facility with applicant and hired Administrator. All bathrooms were clean, had grab bars, and non-slip flooring and/or mats in showers for resident use. Hot water was checked at 105.2 degrees Fahrenheit. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAINT JEANNE CARE HOME, LLC	FACILITY NUMBER: 496804254
	VISIT DATE: 09/13/2024

NARRATIVE

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All resident rooms, common areas, and outside spaces were found to be clean and orderly. Facility had sufficient lighting in resident rooms, bathrooms, and common areas. Medications will be locked up in cabinets set up for centrally storing medications. All disinfectants/cleaners were locked up and inaccessible. All exits were free and clear from obstruction, including the two ramps. Fire extinguishers were serviced and tagged as required-four (4) dated 5/23/24. Sufficient supply of linens, dishes, and furnishings for resident use. Applicant is obtaining the required 72-hour shelter in place supplies for the facility.The backyard and deck were observed to be clean and orderly; The applicant is obtaining patio furniture, including shade umbrellas, for residents to use. All outside walkways/pathways were free and clear of obstruction as required. The applicant will be ensuring a sturdy gate is added off the backyard deck/ramp, where there are three steps down onto the cement yard, to help ensure health & safety of residents in care. The facility's outside buildings, consisting of a large activity room, a staff sleeping room, an office room, small storage room, and large storage room; These outside facility buildings will be inspected in the fire clearance request the LPA will send out once required documents are received from the applicant.

Once the fire clearance is obtained, the LPA will contact the applicant to discuss the new fire clearance approval. LPA will notify the application unit when all discussed items are obtained, and completed, including new fire clearance.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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