216800503-10-23-2024-21-AS-CFES-DABQXY-20241023123420

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800503
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:34:27 PM

Document Has Been Signed on 10/23/2024 12:34 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 HOUSE		FACILITY NUMBER:	216800503
ADMINISTRATOR:	MARIA DEL PILAR DE OLAVE		FACILITY TYPE:	740
ADDRESS:	566 WAKEROBIN LANE		TELEPHONE:	(415) 491-0604
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	5	CENSUS: 3	DATE:	10/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Licensee/Administrator, Pilar De Olave		TIME COMPLETED:	12:45 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	At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Pilar De Olave. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 5 residents, where 4 can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 3 Residents in care and 1 staff member on-site. At approximately 9:30AM, 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 9:45AM, LPA conducted a walk-though of the facility. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control Plan on file. Facility is a 1 story building with 4 Resident bedrooms, 2 bathrooms, and common spaces. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Fire extinguishers were last inspected April 2024. Smoke detectors and carbon monoxide detectors were tested and operational. At approximately 9:50AM, LPA reviewed staff files and resident files. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Administrator's Certificate for Pilar De Olave (6030062740) was expired as of December 2021. Per Licensee, they have been unable to complete their in-person Continued Education Units (CEUs). Licensee informed LPA that they have not submitted an application to the Department to renew their certificate for this reason. LPA informed Licensee to submit their application for renewal. During visit, LPA observed Licensee begin to fill renewal application out (deficiency cited, see LIC809D, regulation 87405(a)). Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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: SHALOM HOUSE	FACILITY NUMBER: 216800503
	VISIT DATE: 10/23/2024

NARRATIVE

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Continued from LIC809

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

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, Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/23/2024 12:34 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(a)

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made and interview conducted, Licensee did not comply with the section cited above. Licensee did not ensure that they submitted an application to renew their Administrator’s Certification with the Department. Licensee’s last administrator certification was December 2021. This regulation poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 11/04/2024
	Plan of Correction
1 2 3 4	Licensee to submit renewal application to Department immediately and notify LPA once they are on the pending renewal list. During visit, LPA observed Licensee begin to fill out renewal application.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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