210109691-5-20-2022-21-AS-FSAI-CELSVL-20220520141255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:13:03 PM

Document Has Been Signed on 05/20/2022 02:13 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:	D STREET RESIDENTIAL SUPPORT SERVICES		FACILITY NUMBER:	210109691
ADMINISTRATOR:	ASHKENAY, REBECCA		FACILITY TYPE:	735
ADDRESS:	527 D STREET		TELEPHONE:	(415) 454-9920
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 10		CENSUS:	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Counselor, Anders Helmersson		TIME COMPLETED:	02:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted by Counselor, Anders Helmersson and was granted access into the facility.

LPA toured the facility with Counselor, Anders Helmersson on this date and time. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected and found to be appropriate at this time. Fire extinguisher were found to be last charged April 2022. Facility smoke detectors are hard wired and sound directly to the fire station. Downstair(s) Carbon Dioxide detector was tested and found to be operational during the inspection. Upstairs Carbon Dioxide detector(s) was tested and found to be operational during the inspection. Water temperature measured at 115 degrees within Title 22 regulations of 105-120 degrees. However, LPA did observe a clog in the sink in the upstairs bathroom. The bathroom is utilized for client use (Photo taken-See LIC 809D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored per regulations. LPA observed that there are two refrigerators both had an ample amount of food. Toxins and cleaning supplies are stored in a locked cabinet under the kitchen sink. Dangerous items were stored inaccessible to clients. Medications were locked and centrally stored inside the Medication room which was also locked. There was a supply of cleaners, hygiene products and paper products available for clients. The bathrooms designated for clients at the facility were supplied with sufficient hygiene supplies

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. N95 Fit testing has not occurred (See LIC 9102).

LPA requested the following documents to be sent to CCL:

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: D STREET RESIDENTIAL SUPPORT SERVICES	FACILITY NUMBER: 210109691
	VISIT DATE: 05/20/2022

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LPA requested the following documents to be sent to CCL:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 Chapter 1 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights were provided.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 02:13 PM - It Cannot Be Edited

Created By: Farhaan Sarangi On 05/20/2022 at 01:55 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: D STREET RESIDENTIAL SUPPORT SERVICES	FACILITY NUMBER: 210109691
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(3)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 1 out of 3 bathroom sinks were observed to have a clog, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Plan of Correction will include unclogging the sink and a plan on how future compliance will be met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Farhaan Sarangi

LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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