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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125001012
Report Date: 10/07/2024
Date Signed: 10/07/2024 02:00:08 PM

Document Has Been Signed on 10/07/2024 02:00 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/
DIRECTOR:		ROSE, TINAFACILITY TYPE:
735
ADDRESS:207 NEWELL DRIVETELEPHONE:
(707) 725-5704
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 4CENSUS: 4DATE:
10/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kaye HahnerTIME VISIT/
INSPECTION COMPLETED:
02:15 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
At approximately 1:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident that occurred on 09/08/2024. LPA met with Direct Support Personnel (DSP) Kaye Hahner and reviewed records. Based on a review of records, Client, C1, is supposed to have staff nearby while at the facility and with then at all times in the community for their safety. On 09/08/2024, C1 returned from an outing with staff and left again soon after, without staff knowledge. C1 returned approximately 15 minutes later.
LPA reviewed records and observed C1's Individual Service Plan (ISP) was last updated 03/2024 and their Individual Program Plan, (IPP) was last updated 06/20/2024. The IPP notes C1 is to have staff nearby while at home and at all times in the community. The ISP does not mention this observation note and has not been updated to reflect this new behavior. C1's physician report was faxed from the doctors office and is missing page two, which notes whether C1 is able to leave the facility unassisted.

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 Kaye Kahner and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 2
Document Has Been Signed on 10/07/2024 02:00 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 10/07/2024 at 01:45 PM
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: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
80068.3(a)

1
2
3
4
5
6
7
80068.3 Modifications to Needs and Services Plan:(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually.
1
2
3
4
5
6
7
Licensee to ensure clients service plan is updated as needed to address new behaviors. Licensee to update C1's plan and submit self certification to CCL by POC date of 10/25/2024.
8
9
10
11
12
13
14
These modifications shall be maintained in the client's file. This requirement is not met as evidenced by: Based on records reviewed, C1's service plan was not updated. This poses a potential Safety risk.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2