210109691-8-23-2023-21-AS-CFES-CUYVZ7-20230823165215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210109691
Report Date: 08/11/2023
Date Signed: 08/23/2023 04:52:27 PM

Document Has Been Signed on 08/23/2023 04:52 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: 10	DATE:	08/11/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Staff Member, Sheila (Iya) Pacheco, and Team Leader, Chris Speed		TIME COMPLETED:	09:22 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	At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Iya Pacheco. Team Leader, Chris Speed, arrived during visit at approximately 9:35AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance for 10 Ambulatory Clients with a total capacity for 10 Clients. Upon arrival, LPA was informed that there were 10 clients in care and 1 staff member on-site. At approximately 9:25PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:50AM, LPA reviewed a sample size of 6 Client files which were found to be well organized, thorough and contained the required documentation. Facility does not assist clients with P&I monies at this time. At approximately 11:50AM, LPA reviewed a sample size of 6 staff files. Review of staff files indicated that 6 of 6 staff files did not have current First Aid/CPR certificates. Per Title 22 Regulations, staff providing direct care and supervision shall receive First Aid training from qualified agencies (See Deficiency Page, Regulation 80075(f)). At approximately 12:30PM, LPA reviewed a sample size of 6 Client Medication Records. Records were observed to be centrally stored and secure. At approximately 1:20PM, LPA conducted staff interviews. LPA conducted a walk through of the facility. Carbon Monoxide Detectors were tested and operational. LPA observed that the facility does not have a evacuation chair at this time. Team Leader understands that an evacuation chair needs to be on-site to remain compliant with Health and Safety Code (See Technical Advisory 1565(f)(1). LPA observed that there is a locked fridge located in the facility kitchen as well as signs indicating that foods is only available at certain times (pictures taken). Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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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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: 08/11/2023

NARRATIVE

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Continued from LIC809
Per Team Leader, the locked fridge is for staff but client food is also stored in the locked fridge at their request to keep personal food items from being stolen. LPA informed Facility that a locked fridge waiver will need to be submitted to the Department for review and approval if they want to keep Client food in the locked fridge.
LPA observed that most fire extinguishers were last inspected August 2023. 1 fire extinguisher located in the staff room was observed to be last inspected March 2022 (See Technical Violation, Regulation 80020).

At approximately 2:20PM, LPA conducted Client Interviews.

Facility is changing Administrator duties to John Ahrens. LPA is requesting the following Administrator paperwork:
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid/CPR Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)
Administrator Documents to be submitted to CCL by due date of Monday, 08/21/2023.

LPA is requesting the following documents to update the facility file:

Affidavit regarding Client/Resident Cash Resources (LIC400)
Designation of Facility Responsibility (LIC308)
Emergency Disaster Plan (LIC610D)
Updated Personnel Report (LIC500)
Surety Bond (LIC 402)
Register of Clients/Residents (LIC9020)

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 09/14/2023.

Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 04:52 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 08/11/2023 at 01:22 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review, the Licensee did not comply with the section cited above for 6 of 6 staff files and did not ensure that there were current First Aid and/or CPR certificates. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2023
	Plan of Correction
1 2 3 4	Licensee to submit self certification that First Aid and CPR Training will be conducted for all direct care staff by POC due date of 08/12/2023. Licensee to ensure that at least one staff member on-site has current CPR/First Aid by 08/11/2023. Licensee submit Staff Member List and their Proof of First Aid and CPR certificates to CCL by POC Due Date of 08/21/2023.

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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: 08/11/2023

NARRATIVE

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Continued from LIC809C

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, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Team Leader. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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