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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 01/04/2024
Date Signed: 01/04/2024 04:14:40 PM

Document Has Been Signed on 01/04/2024 04:14 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:
94947
CAPACITY: 15CENSUS: 14DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Team Leader, Jaqueline BurnsTIME COMPLETED:
04:30 PM
NARRATIVE
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At approximately 9:25AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an annual required inspection and was greeted by staff. Team Leader, Jaqueline Burns arrived at a later time.

LPA initiated a tour of the facility at approximately 10:15AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 119 and 124 degrees F. One of which is not within the range of 105 to 120 degrees F allowed per regulation. Team Leader turned down the water heater. Extra hygiene products and linens were available. Additional cleaning supplies and disinfectants are stored in a locked closet which is inaccessible to clients in care. However, LPA observed cleaning products (clorox toilet bowl cleaner, disinfectant wipes, comet) in bathroom(s) and dining room accessible to clients in care.

Facility has at least two days of perishable and one week of non-perishable foods which was stored per regulation and were of quality. Medications were centrally stored and locked. Emergency food and water supply are stored in locked basement.

LPA observed fire extinguishers last serviced in January 2019, December 2022, and October 2023. Facility staff immediately called for annual maintenance to be performed in order to get all extinguishers up to date. Facility has smoke detectors as well as sprinklers that are hardwired to the local fire department. Sprinklers were last inspected December 2023. Carbon Monoxide was tested and operational during visit. Most recent fire/disaster drill was conducted 01/02/2024.

Continued on LIC809C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SERVICES
FACILITY NUMBER: 210109022
VISIT DATE: 01/04/2024
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Continued from LIC809

Per conversation with Team Leader, there has been construction in the house to remodel the bathrooms in the last couple months, as well as upcoming renovations to the laundry room access space as well as the outdoor area. LPA had a conversation with Team Leader about ensuring that prior to any construction to the home, Administrator/Licensee must notify Community Care Licensing (CCL) in writing of their plans for construction as well as provide CCL with a plan for ensuring health and safety of clients during construction.

Five client files were reviewed. Staff files were not available on site for LPA to review at the time of inspection. However, they were accessible on Team Leaders computer for review. Administrator on file has retired and is no longer serving as the Administrator for this facility. For the time being, John Ahrens (6067013735, expires 07/16/2025) is serving as the Administrator for this facility until Team Leader, Jaqueline Burns completes their Administrator Certification.

Facility to submit the following documents to CCL by 02/04/2024:
LIC 308 Designation of Facility Responsibility (signed by the licensee representative)
LIC 500 Personnel Report
LIC9020 Register of Clients

Facility to provide the following documents for change of Administrator to CCL by 02/04/2024:
LIC 501 Personnel Record or Administrator Resume
Administrator Certificate
Fingerprint association to facility
Board resolution

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: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/04/2024 04:14 PM - It Cannot Be Edited


Created By: Helena Rummonds On 01/04/2024 at 03:41 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: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Toxic substances were immediately removed from bathrooms and dining area. Team Leader to submit plan on how to keep toxic substances away from clients in care. After locks are installed on bathroom cabinets, Team Leader to provide proof of installation.
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:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/04/2024 04:14 PM - It Cannot Be Edited


Created By: Helena Rummonds On 01/04/2024 at 03:41 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: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 sinks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Team leader to submit proof of water temperature lowered to 105-120 degrees F in sinks accessible to clients in care by POC due date of 01/11/2024.
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:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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