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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800503
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:49:45 PM


Document Has Been Signed on 07/11/2024 03:49 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:SHALOM HOUSEFACILITY NUMBER:
216800503
ADMINISTRATOR:MARIA DEL PILAR DE OLAVEFACILITY TYPE:
740
ADDRESS:566 WAKEROBIN LANETELEPHONE:
(415) 491-0604
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:5CENSUS: 3DATE:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Licensee/Administrator, Pilar De OlaveTIME COMPLETED:
02:30 PM
NARRATIVE
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At approximately 2:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit, and met with Licensee/Administrator, Pilar de Olave.

During the course of the Complaint Investigation dated for July 11, 2024, the Department learned that the Facility did not submit written reports to Community Care Licensing (CCL) per regulation. The Department received information that Resident 1 (R1) passed away on 07/03/2024. Licensee confirmed that they did not submit a Death Report or Special Incident Form (LIC624) to CCL timely (deficiency cited, see LIC809D, regulation 87211(a)(1)(D)). LPA and Licensee discussed the importance of reporting incidents in a timely manner.

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, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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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Document Has Been Signed on 07/11/2024 03:49 PM - It Cannot Be Edited

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: SHALOM HOUSE
FACILITY NUMBER: 216800503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(A) Death of any resident from any cause regardless of where the death occurred...
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Licensee provided copy of Death Report for R1 during visit. Licensee to submit self-certification stating that they understand the regulation requiring that reports are submitted timely to the Department by POC due date of 07/21/2024.
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This requirement is not met as evidenced by:
Based on interview conducted and record review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.
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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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