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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001012
Report Date: 08/20/2024
Date Signed: 08/20/2024 09:41:58 AM

Document Has Been Signed on 08/20/2024 09:41 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:CIDER HOUSEFACILITY NUMBER:
125001012
ADMINISTRATOR/
DIRECTOR:		ROSE, TINAFACILITY TYPE:
735
ADDRESS:207 NEWELL DRIVETELEPHONE:
(707) 725-5704
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 4CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Talisha RoseTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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At approximately 8:10AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted by the facility on 07/29/2024. LPA met with Administrator Talisha Rose and reviewed records. On 07/18/2024, Facility staff were conducting a pill count and observed Client, C1, had only received 1 pill of a 2 pill order for the previous 4 days. The medication usually is packaged together, but the recent order came packaged separately. On 07/29/2024, Administrator conducted retraining with responsible staff and posted a reminder to all other staff to ensure they slow down and pay attention during medication time. An immediate civil penalty is being issued in the amount of $250 for this repeat violation in a 12 month period.

During this visit, LPA received another incident report regarding Client, C2, not receiving 2 doses of their medication. The medication was ordered on 08/10/2024, but the pharmacy made an error and sent the refill request to the wrong physician. The missing medication was noticed 08/19/2024, as it was not available to administrator. Administrator contacted pharmacy and physician and was informed the medication would be filled immediately. Facility has updated their medication ordering process to keep better track.

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: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 09:41 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 08/20/2024 at 08:48 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
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 as directed by Physician. Administrator conducted retraining with responsible staff. POC cleared at time of visit.
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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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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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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