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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126803768
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:36:39 PM

Document Has Been Signed on 10/09/2023 12:36 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:NEW CHOICESFACILITY NUMBER:
126803768
ADMINISTRATOR:ROSE, TINAFACILITY TYPE:
735
ADDRESS:2416 UNION STREETTELEPHONE:
(707) 476-3476
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY: 4CENSUS: 4DATE:
10/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kim VargasTIME COMPLETED:
12:45 PM
NARRATIVE
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At approximately 11:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a medication error that was reported to CCL. LPA met with House Manager Kim Vargas and reviewed records. The error occurred due to a new client moving into the home and a part time staff (S1) was not familiar with their medications. The error was discovered the following day when the house manager reminded the staff of the evening medication pass. Physician was notified.
S1 was retrained and reviewed facility procedures. House manager has updated all staff on all medications for the new individual.

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 the House manager and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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 10/09/2023 12:36 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 10/09/2023 at 12:13 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: NEW CHOICES
FACILITY NUMBER: 126803768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2023
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: Based on
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Licensee to ensure medications are administered as ordered by Physician. Staff was retrained. POC Cleared.
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Records reviewed, Licensee did not ensure medication was administered as ordered by Physician. This poses an Immediate health risk to clients in care.
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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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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