216800881-4-14-2022-21-AS-CFGS-CDGNV6-20220414104725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:49:32 AM

Document Has Been Signed on 04/14/2022 10:49 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 LUIS HOUSE		FACILITY NUMBER:	216800881
ADMINISTRATOR:	TOOTLE, MICHELLE		FACILITY TYPE:	735
ADDRESS:	396 SAN LUIS WAY		TELEPHONE:	(415) 897-5716
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY: 6		CENSUS: 5	DATE:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Veronica Samuel - staff		TIME COMPLETED:	10:47 AM

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	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Veronica Samuel. Assistant Program Director was contacted by phone and arrived during the visit. Some clients were present at the facility. Some clients at this facility are in day program and/or zoom activities. There are activities planned for clients during the day if they want to participate. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 4/14/2022 with staff Veronica facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 07/2021 at the time of the visit. Carbon monoxide detector was operational during visit. Sample test of Smoke detectors was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 102.0 degrees F and 102.5 degrees F in 2 out of 2 faucets falling out of Title 22 acceptable regulations of 105 to 120 degrees F. (see LIC 809-D) Disaster Drills have been conducted monthly with the last one being conducted on 3/31/2022. Continued LIC 809-C

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: 04/14/2022

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 3

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
	VISIT DATE: 04/14/2022

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
26
27
28
29
30
31
32

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility; hand sanitizer designated for visitors are at entrance. Staff before coming into work has temperature checked. Facility has PPE supply stored in the garage and office room. There has been new staff hired and no new clients since COVID-19. Clients’ medications are stored and locked in medication cabinet inside office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available zoom and telephone calls when contacting with family members and others. Staff stated that they have had all PPE training required on file and staff had N-95 fit testing conducted.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Department is requesting Licensee to update the following documents and submit to CCL by 4/21/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
Copy of Lease Agreement &/or Deed
Copy of permits for office room built in garage
Copy of updated sketch of the facility.

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: 04/14/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/14/2022 10:49 AM - It Cannot Be Edited

Created By: Carla Fernandes-Goes On 04/14/2022 at 10:23 AM

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 clients' bathroom faucets which poses/posed a potential health, safety or personal rights risk to persons in care. During this visit, LPA checked hot water temperature in clients' bathroom faucets which measured between 102.0 degrees F and 102.5 degrees F .
	POC Due Date: 04/28/2022
	Plan of Correction
1 2 3 4	Facility agrees to check on hotwater temperature to ensure that it stays in compliance w/ Title 22 Regulations. Facility to submit CCLD with a 7 day hotwater temperature log for clients' bathroom faucets by POC due date 4/28/2022.

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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Carla Fernandes-Goes

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3