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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800416
Report Date: 04/14/2022
Date Signed: 04/18/2022 08:33:51 AM

Document Has Been Signed on 04/18/2022 08:33 AM - 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:SAN BENITO HOUSEFACILITY NUMBER:
216800416
ADMINISTRATOR:ANN GOUGHERFACILITY TYPE:
735
ADDRESS:6 SAN BENITO WAYTELEPHONE:
(415) 895-1624
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ann Gougher - administratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and was welcome by Ann Gougher administrator during this visit. The purpose of the case management visit is to obtain additional information regarding client C1 submitted to the Department. Clients were arriving from day program during this visit and 1 client was at facility.

Department learned that on 2/5/2022 client C1 who was admitted on 1/12/2022 left the facility unassisted at 8:40 AM and returned at 8:45 AM. In addition, on 3/16/2022 client C1 left facility at 7:30 PM and came back around 8:40 PM. Client C1 has a physician’s report dated 1/2022 stated that resident is able to leave facility unassisted. Client C1 also has a cellphone which is carried all the time with client. Facility and GGRC are looking for a different placing for client as per administrator and other ways that might work better for client C1 stay at facility.
Administrator understands that due to the fact that client C1 has a LIC 602 stating that client "is able to leave facility unassisted", this can become a personal rights issue. However, in the case that there are concerns regarding leaving client C1 go out on by itself, facility will need to work with physician and GGRC. Client C1 IPP dated 1/30/2020 and reviewed on 2/10/2022. The IPP 1/20/20 doesn't mention anything agreeing and/or against client leaving facility unassisted and IPP reviewed/management meeting for 2/10/2022 has not been received by facility from GGRC.

Department is requesting copy of 2//10/2022 as soon as possible.

There were no deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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