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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001012
Report Date: 09/20/2023
Date Signed: 09/20/2023 12:07:10 PM

Document Has Been Signed on 09/20/2023 12:07 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CIDER HOUSEFACILITY NUMBER:
125001012
ADMINISTRATOR:ROSE, TINAFACILITY TYPE:
735
ADDRESS:207 NEWELL DRIVETELEPHONE:
(707) 725-5704
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 4CENSUS: 4DATE:
09/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Talisha RoseTIME COMPLETED:
12:20 PM
NARRATIVE
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At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a medication error reported by the facility on 09/05/2023. LPA met with Administrator Talisha Rose. The medication error was due to a staff missing one pill while preparing medication for a client. The pill was found the following shift, still in the bubble pack. Client did not receive medication as prescribed by physician. This is a repeat violation within a 12 month period. ****A civil penalty is being issued in the amount of $250.****
LPA requested Licensee to provide all staff medication training from an outside provider.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Talisha Rose and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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Document Has Been Signed on 09/20/2023 12:07 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 09/20/2023 at 11:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CIDER HOUSE
FACILITY NUMBER: 125001012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Licensee did
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Licensee to ensure clients receive assistance with medications. Licensee to provide training from an outside source for all staff on medication assistance. Training to be scheduled by POC date of 9/21/2023.
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not ensure clients received proper assistance with medications. This poses an immediate Health, Safety or personal rights risk to residents.
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Self certification of completed training to be submitted to CCL by 10/20/2023.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
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