<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800343
Report Date: 09/25/2023
Date Signed: 09/25/2023 12:46:14 PM

Document Has Been Signed on 09/25/2023 12:46 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:BAY HOME INCFACILITY NUMBER:
216800343
ADMINISTRATOR:KAREN BIRDFACILITY TYPE:
735
ADDRESS:19 HEARTHSTONE CTTELEPHONE:
(415) 507-0235
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Administator, Karen BirdTIME COMPLETED:
12:55 PM
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
Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct an Annual Required inspection and met with Administrator, Karen Bird.

Upon arrival, LPAs initiated a tour of the facility around 9:09AM and made the following observations: Facility was at a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature measured at 125 degrees F, in sink used by clients which are not within the range of 105 to 120 degrees F allowed per regulation, and Licensee immediately turned down water heater. Extra hygiene products and linens were available. Cleaning supplies and disinfectants are stored locked and inaccessible to clients in garage. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility has emergency food and water supplies.

Fire extinguishers were last inspected June 2023. Facility has Smoke and Carbon Monoxide detectors located throughout the facility that were tested and in working condition. Most recent fire drill and disaster drill was conducted June 2023.

Six staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Karen Bird expires 06/09/2024. Medications and medication records were reviewed. Client cash resources were also reviewed.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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 3
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: BAY HOME INC
FACILITY NUMBER: 216800343
VISIT DATE: 09/25/2023
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
26
27
28
29
30
31
32
Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 10/25/2023:
LIC 500 Personnel Summary
LIC 400
Updated Surety Bond
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 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 provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 09/25/2023 12:46 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 09/25/2023 at 12:15 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: BAY HOME INC
FACILITY NUMBER: 216800343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having the water temperature measure above regulation which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
1
2
3
4
Licensee immediately turned down water heater and licensee will submit self certification to LPA by POC due date of 09/26/2023.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3