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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800261
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:33:54 PM

Document Has Been Signed on 04/04/2024 03:33 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:LIFEHOUSE-LAUREL PLACEFACILITY NUMBER:
216800261
ADMINISTRATOR/
DIRECTOR:		MIKE SUSFACILITY TYPE:
735
ADDRESS:210 LAUREL PLACETELEPHONE:
(415) 456-7141
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
04/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:House Manager, Makela MooreTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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At approximately 1:20PM, Licensing Program Analysts (LPAs) Felias and Florio arrived unannounced to conduct a Required 1 Year visit and met with House Manager, Makela Moore. Facility is an Adult Residential Home that provides care and assistance for Adults with Developmental Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPAs were informed there were 6 clients in care and 1 staff member on site. LPAs were also informed that all clients were out of the community attending Day Program.

LPAs reviewed staff and client files, client medication, and P&I monies. All files were found to be well organized, thorough and contained the required documentation. Staff files had current First Aid certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure.

Administrator's Certificate, Michael (Mike) Sus (6018707735) was current with an expiration date of 07/25/2024.

LPAs also followed up on an incident report that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 08/25/2023. Report stated that on 08/23/2023, the facility House manager was notified by staff that they had not been administering Client 1's (C1's) medication per physician order. The staff member informed the house manager that this mistake was from the time frame of July 2023 to August 2023. Per report, C1 was being given 1 tablet of medication instead of 2 tablets. Facility conducted an in-service training for staff member. Facility made all appropriate notifications per regulation (this deficiency has been cited, see LIC809D, Regulation 80075(b)). LPAs were provided with a copy of training documentation, dated 08/25/2023. LPAs cleared deficiency cited today during visit.

LPAs also cleared the previous deficiency cited on 01/31/2024 during visit.

Continued on LIC809C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 03/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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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: LIFEHOUSE-LAUREL PLACE
FACILITY NUMBER: 216800261
VISIT DATE: 04/04/2024
NARRATIVE
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Continued from LIC809

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 05/04/2024.

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, LIC811 (Confidential Names), Appeal Rights, and Plan of Corrections Letters, discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

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

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2024 03:33 PM - It Cannot Be Edited


Created By: Julie Florio On 04/04/2024 at 03:06 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: LIFEHOUSE-LAUREL PLACE
FACILITY NUMBER: 216800261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on incident report provided, the Licensee did not comply with the section cited above. LPAs observed that facility staff did not administer medication per physician’s order. This poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee submitted documentation of training for staff member reviewing the 5 Rights of Medication Administration. Documentation was dated for 08/25/2023. Deficiency cleared during visit.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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