216800652-9-12-2023-21-AS-CFES-CVLTZL-20230912151030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800652
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:10:37 PM

Document Has Been Signed on 09/12/2023 03:10 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BELLE HOUSE		FACILITY NUMBER:	216800652
ADMINISTRATOR:	ANTYON LIGGINS		FACILITY TYPE:	735
ADDRESS:	865 BELLE AVENUE		TELEPHONE:	(415) 457-9632
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 6		CENSUS: 6	DATE:	09/12/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Staff Members, Jonteja Fowler and Latanja Gibson, Manager of Program Operations, Kayla Hotchkiss		TIME COMPLETED:	03:15 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 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Jonteja Fowler and Latanja Gibson. Manager of Program Operations, Kayla Hotchkiss, arrived at approximately at 10:35AM. Program Manager, Yvette Morgan, arrived at approximately 11:00AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 6 clients in care, with 4 clients out of the community attending Day Program. LPA was also informed there were currently 2 staff members on site. At approximately 10:00AM, LPA reviewed 3 client medication records with Staff Member, Program Manager and Manager of Program Operations. Facility chooses to use a Medication Administration Record (MAR) to record when medications are being administered to Clients. During medication review, LPA observed that two Client Medication Records did not match the amount of medication dispensed. Medication Records for Client 1 (C1) and Client 2 (C2) were not initialed or documented appropriately in the Facility's (MAR). Review of documentation indicated that C1 and C2 went home to see family, but that facility staff forgot to document that the medications were given to family members to administer for Clients off-site. LPA reviewed staff files and found no record of Medication Training being done. Facility was unable to provide documented proof to show that Facility Staff have had Medication Training as required (This Deficiency has been cited, see LIC809D, Regulation 80065(f)). LPA also observed that Client 3 (C3) had a medication listed on the MAR that was to be given daily. This medication was observed to not have initials or be administered for the month of September 2023 but was initialed and administered for the month of August 2023. Per discussion with Program Manager and Manager of Program Operations, the Facility had been purchasing the medication as over-the counter. Facility conducted a Medication Audit in August 2023 and discovered that this medication was on the MAR but had not been filled by the pharmacy since 2018. Review of C3's file does not show an active order or discontinued order for this medication. C3's most updated physician orders does not list this medication as a prescription. Facility immediately contacted C3's pharmacy and physician to determine if this medication was still current or if it had been discontinued. As of today, Facility has yet to receive a response or clarification on whether or not C3 should continue with this medication (See Technical Advisory, Regulation 80075(b)(5)(A)). Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLE HOUSE	FACILITY NUMBER: 216800652
	VISIT DATE: 09/12/2023

NARRATIVE

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Continued from LIC809

LPA, Program Manager, and Manager of Program Operations discussed the following:

The importance of documenting on the Facility's MAR properly when clients leave the facility for extended periods of time and ensuring the record's accuracy
Documenting communication with Client Physicians and Responsible Parties when it concerns the care being provided at the facility

LPA is requesting the following documents in order to update facility file:

Affidavit regarding Client/Resident Cash Resources (LIC400)
Designation of Facility Responsibility (LIC308)
Emergency Disaster Plan (LIC610D)
Updated Personnel Report (LIC500)
Surety Bond (LIC 402)
Register of Clients/Residents (LIC9020)

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 10/12/2023.

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, LIC811 (Confidential Names), LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Program Manager. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2023 03:10 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 09/12/2023 at 02:34 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: BELLE HOUSE	FACILITY NUMBER: 216800652
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(f)

Personnel Requirements

(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review and Observations made, the Licensee did not comply with the section cited above for 2 of 6 Client medication records and did not ensure that records were documented accurately. Staff Files reviewed did not show record of Medication Training being completed. This poses a potential health, safety or personal rights risk to Clients in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee to conduct an In-Service Training with all Direct Care Staff reviewing Medication Training and Proper Medication Documentation. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 09/22/2023.

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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