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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102765
Report Date: 05/09/2022
Date Signed: 05/09/2022 10:43:53 AM

Document Has Been Signed on 05/09/2022 10:43 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:CEDARS OF MARIN ROSS CAMPUS, THEFACILITY NUMBER:
210102765
ADMINISTRATOR:ANDERSON, STACYFACILITY TYPE:
735
ADDRESS:115 UPPER ROADTELEPHONE:
(415) 454-5310
CITY:ROSSSTATE: CAZIP CODE:
94957
CAPACITY: 55CENSUS: 45DATE:
05/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Stacy Anderson-Administrator & Rodric Robinson-Dir. of Residential ServicesTIME COMPLETED:
10:41 AM
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
Licensing Program Analysts (LPA) Hansen arrived unannounced to conduct a Case Management and was greeted outside of building by (Mgr of Peterson Hall) Rosemond who informed, over the weekend they had 2 clients and 1 staff test positive for COVID. LPA donned appropriate garb for visit.

At 9:25am LPA met with Administrator Stacy Anderson and Roderic “Rob” Robinson Director of Residential Services following up on a self-reported Incident Report received on 5/3/22 & 5/4/22 about a death of a client who resided at the facility. LPA spoke with Roderic Robinson Director of Residential Services. C1 died at Marin General Hospital on 5/4/22. Staff notice that client was not looking well on 4/21/22 and was seen by primary care doctor in office and given antibiotics. On 4/23/22 client presented significantly worse, 911 was called and was taken to the hospital. Client showed no symptoms prior to 4/19/22. C1 was diagnosed with Pneumonia and Sepsis and admitted to the hospital (ICU). C1’s condition deteriorated while in ICU, with low brain activity, being put on a ventilator and having seizure activity. C1’s family decided to stop life sustaining measures. C1 died at hospital on 5/4/22.

LPA interviewed staff and acquired documents.

Administrator contacting conservator for additional documents (D.C. & Hospital records)

No deficiencies cited during the visit.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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 1