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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 02/06/2024
Date Signed: 02/06/2024 03:29:42 PM

Document Has Been Signed on 02/06/2024 03:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NOVATO RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109022
ADMINISTRATOR:ROBIN HUGHESFACILITY TYPE:
735
ADDRESS:1333 SEVENTH STREETTELEPHONE:
(415) 897-7195
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 15CENSUS: 14DATE:
02/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:House Manager, Jacquie BurnsTIME COMPLETED:
03:45 PM
NARRATIVE
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At approximately 2:15 PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a Case Management Inspection on an Incident Report dated 01/10/2024. LPA met with Team Leader, Jacquie Burns and discussed the purpose of the visit.

Incident Report dated 01/10/2024: Client 1 (C1) did not receive a scheduled dose of Metformin. Staff 1 (S1) could not recall why it was not administered when Team Leader asked about the medication error, but S1 claimed that its possible that the medication was in a new medication roll and it was not visible to them at the time, causing them to forget to administer the medication.

Per conversation with Team Leader, staff members handle medication passes differently, with some staff allowing clients to sleep in and get their medications when they wake up. Team Leader has had conversations with staff in the past about making sure that if a client doesn't show up for medication pass, that it is their responsibility to get the client and ensure that they are taking their meds within the required time frame. In this instance, it is unknown why the medication error occurred. In addition, the client did not suffer any adverse affects.

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.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Team Leader. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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 02/06/2024 03:29 PM - It Cannot Be Edited


Created By: Helena Rummonds On 02/06/2024 at 02:40 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: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ...
(4)The licensee shall assist residents with self-administered medications as needed.
This requirement was not as evidenced by:
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Team leader agrees to submit documentation outlining the facilities updated medication procedures. The updated medication procedures should include how facility is to ensure that medication errors are avoided in the future.
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Based on record review, the licensee did not comply with the section cited above by not ensuring that the medications were given as prescribed.
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Team leader agrees to forward to LPA the email that is sent out to all staff regarding the updated medication procedures. Documentation to be provided to LPA by POC due date of 02/07/2024.

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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:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024


LIC809 (FAS) - (06/04)
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