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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803405
Report Date: 10/21/2024
Date Signed: 10/21/2024 12:23:34 PM

Document Has Been Signed on 10/21/2024 12:23 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAROLE SUND CENTERFACILITY NUMBER:
126803405
ADMINISTRATOR/
DIRECTOR:		OTT, SUZETTEFACILITY TYPE:
775
ADDRESS:4635 BROADWAYTELEPHONE:
(707) 442-3969
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 30CENSUS: 12DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Michelle RussoTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced at this Licensed Day Program to conduct an Annual Required Inspection. LPA met with Michelle Russo and toured the facility. This Day Program operates 7 days a week. There were 12 Clients and 6 Staff present at the time of this inspection. The facility consists of offices, a large activity room, large outdoor areas containing a garden, chickens and goats. LPA observed the facility was a comfortable temperature and found all exits and walkways to be unobstructed. The facility grounds were kept clean and without hazards. Clients attend the garden and animals as part of the program.
Toxins are centrally stored and not accessible. Water temperature measured within regulation between 105 and 120 degrees F. at faucets accessible to clients. Client money is not handled by facility. Day Program staff do not handle client medication.

At approximately 11:30AM, LPA reviewed 6 client files and found files to be thorough and contain current client care assessments and individualized Service Plans. Files did not contain medical assessments. Staff records were also found to be current, including staff first aid and CPR training verification. Disaster/fire drills are conducted monthly.

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 Michelle Russo and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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 10/21/2024 12:23 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 10/21/2024 at 12:06 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: CAROLE SUND CENTER
FACILITY NUMBER: 126803405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review], the licensee did not comply with the section cited above in 6 of 6 clients records reviewed. Filed did not contain medical assessments, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee to ensure client records contain medical assessments. Licensee to review all files and submit self certification that all clients have received a medical assessment. Self certification shall be submitted to CCL by POC date of 11/22/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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