216800847-3-23-2023-21-AS-CFES-CQ83A6-20230323180412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800847
Report Date: 03/23/2023
Date Signed: 03/23/2023 06:06:15 PM

Document Has Been Signed on 03/23/2023 06:06 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:	CEDARS WALTER HOUSE		FACILITY NUMBER:	216800847
ADMINISTRATOR:	STACY ANDERSON		FACILITY TYPE:	735
ADDRESS:	1842 NOVATO BLVD		TELEPHONE:	(415) 892-1073
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 6		CENSUS: 6	DATE:	03/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Frank Kemmeter		TIME COMPLETED:	06:15 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 9:15AM, Licensing Program Analysts (LPAs) Felias and Alviso arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Frank Kemmeter. The facility provides care to adults with developemental and physical disabilities and has an approved fire clearance for 6 ambulatory clients. Upon arrival, LPAs were informed that 5 of 6 clients were out of the community and the last client was sleeping. At approximately 9:20AM, LPAs conducted a walk through of the facility and observed the following: LPAs observed boxes and personal items along the hallways, common areas, client rooms, and in the garage. Per conversation with Administrator, the house has been undergoing renovations for the past 4 weeks. Renovations included new paint and new flooring. LPAs observed construction workmen on site installing the new flooring. LPAs discussed with Administrator the importance of notifying Community Care Licensing (CCL), when there are any major renovations made which could impact client care. LPAs observed that Client 1's (C1) and Client 2's (C2) bedroom sliding doors were obstructed with personal belongings and other miscellaneous items. Upon observation of the obstructed exits, Administrator immediately informed an employee who ensured the bedroom exits were cleared and accessible. This deficiency was cited, the regulation 80020(a) Fire Clearance - See LIC809D. LPAs also observed 2 out of 3 resident bathrooms. LPAs observed Bathroom 1 smelled strongly of urine, and an open wastebasket with no lid that had used wipes/toilet paper with feces on them and urine soaked depends. Bathroom 2 had an open wastebasket with no lid that had used wipes/toilet paper with feces on them. This deficiency was cited, the regulation 80088(e)(3) Fixtures, Furniture, Equipment, and Supplies - See LIC809D. LPAs also observed that Bathrooms 1, 2, and 3 had no paper towels. Bathroom 2 was observed to have cloth towels located under the sink. LPAs discussed with the Administrator how cloth towels are prohibited and the need to have paper towels available for client use. See Technical Advisory Note for Regulation 85088(c)(4)(B). Continued on LIC809

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 5

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: CEDARS WALTER HOUSE	FACILITY NUMBER: 216800847
	VISIT DATE: 03/23/2023

NARRATIVE

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Continued from LIC 809
The amount of fresh and non-perishable foods was within regulation. LPAs observed dented cans in the facility's emergency food storage. LPAs discussed with Administrator the importance of having properly stored food that is fit to be served to Clients. Administrator stated they will review emergency food storage supply See Technical Advisory Note for Regulation 80076(a)(7).

LPAs observed hash browns and uncooked eggs in a bowl on the counter. LPAs discussed with Administrator the importance of food safety practices. The food on the counter was identified to be for a client who had not eaten breakfast yet due to still being in bed sleeping. See Technical Advisory Note for Regulation 80076(a)(13).

LPAs observed that the facility has added an outside deck. Per conversation with Administrator, they will submit a new facility sketch to CCL.

Water temperature measured in the kitchen and Bathroom 1 within regulation at 105 degrees F which is within regulation for faucets accessible to clients. LPAs and Administrator discussed ensuring that the water temperature is maintained per regulation.

The facility was observed to be at a comfortable temperature and had emergency lighting. Toxins were secure and not accessible to clients. Medication was centrally stored and secure. There was a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Fire extinguishers were last inspected 02/09/2023. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire and earthquake drill was conducted in December 2022.

LPAs reviewed 6 of 6 Client records which were all found to be well organized, thorough and contained the required documentation. First Aid and CPR certification were current for 5 of 5 staff files reviewed. P&I monies were documented, secure and not commingled. Administrator's Certificate (6044558735) was current with an expiration date of 06/27/2023.

Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/23/2023 06:06 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 03/23/2023 at 04:38 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: CEDARS WALTER HOUSE	FACILITY NUMBER: 216800847
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the licensee did not comply with the section cited above in 2 of 6 Client rooms. Client rooms were shown to have personal items, boxes, bags, and micellaneous items blocking their bedroom sliding door exits. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Licensee to submit plan of correction on how the deficiency was corrected to Community Care Licensing (CCL). Licensee to submit photograph as proof that sliding door exits are no longer obstructed. Licensee to submit plan on how facility will maintain compliance with this regulation regarding exits of the facility by POC due date of 3/24/2023.

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: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 03/23/2023 06:06 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 03/23/2023 at 05:16 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: CEDARS WALTER HOUSE	FACILITY NUMBER: 216800847
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(3)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the licensee did not comply with the section cited above in 2 out of 3 resident bathrooms. LPAs observed Bathroom 1 smell strongly of urine, and an open wastebasket with no lid that had used wipes/toilet paper with feces on them and urine soaked depends. Bathroom 2 had an open wastebasket with no lid that had used wipes/toilet paper with feces on them. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/30/2023
	Plan of Correction
1 2 3 4	Licensee to submit a plan of correction stating how the deficiency was corrected. Licensee to submit reciepts of garbage cans with tight fitting lids as proof of purchase. Licensee to submit a written plan regarding the deficiency and how they ensure compliance by POC due date of 3/30/2023.

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: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: CEDARS WALTER HOUSE	FACILITY NUMBER: 216800847
	VISIT DATE: 03/23/2023

NARRATIVE

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Continued from LIC809C

LPA requested the following documents to update facility file:

Administrative Organization (LIC 309)
Affidavit regarding Client/Resident Cash Resources (LIC 400)
Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Surety Bond (LIC 402)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance
Active and Current Administrator Certificate

Documents to be submitted to CCL by due date of 4/23/2023.

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, LIC-809D, LIC9102 Technical Advisory Notes, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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