216800881-6-8-2023-21-AS-SHAN-CSLR72-20230608124539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:45:50 PM

Document Has Been Signed on 06/08/2023 12:45 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:	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:	06/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Andrea Jackson, Administrator (pending certificate)		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Hansen conducted an unannounced annual 1-year required inspection to this facility and was welcome by staff Veronica Samuel. Administrator (pending certification) Andrea Jackson was contacted by telephone and arrived later at facility for this visit. Clients were leaving to attend day program at the time of the visit. There are 5 clients at the facility. LPA toured the facility on 6/8/2023 at 8:20 AM with Staff Veronica Samuel; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 5/24/2023 at the time of the visit. Smoke detectors were found to be operational; although carbon monoxide detector was found to be nonoperational during the visit (see LIC 9102 TV), staff replaced batteries during visit. Hot water temperature measured between 123. & 123.8 degrees F not within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 client’s bathroom while touring facility on 6/8/2023 (see LIC809-D). 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; although kitchen freezer contained unwrapped hashbrowns (see LIC 9102 TV). LPA and staff observed Toxins stored in an unlocked cabinet inside the laundry/garage room with kitchen door to garage open (see LIC 809-D). Dangerous items were stored inaccessible to develop disabled clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All five client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads as required by Title 22. Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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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Document Has Been Signed on 06/08/2023 12:45 PM - It Cannot Be Edited

Created By: Shannan Hansen On 06/08/2023 at 12:09 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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations and interviews conducted, Administrator did not ensure the regulation above do to cleaning solutions, disinfectants and other items that could pose a danger were observed unlocked and accessible to clients. This is an immediate health & safety risk to clients in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Staff was asked to lock the items during the visit. Administrator will train all staff on regulation 80087(g) and submit a copy with date, time, duration, subject, attendees and their signatures to Community Care Licensing (CCL) to clear the citation by POC due date 06/09/2023

Type A

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 during today's visit water tested in 2 of 2 bathrooms read at 123 and123.8 Degrees F . This is a potential health and safety risk to clients in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Facility decreased the water temperature during visit. Facility agrees to keep a daily log of temperature for 1 week.Facility to send in written statement they understand regulation 80088(e)(1). POC due date 6/16/2023

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:

Shannan Hansen

LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
	VISIT DATE: 06/08/2023

NARRATIVE

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A review of five clients files and two client’s medications was conducted at the facility. A sample review of staff records will be conducted at the corporation main office. LPA reviewed client’s files at 9:30 AM and learned that 5 of 5 clients have an updated reappraisal/needs & care plan, and physician’s report on file at this time as required by Title 22 Regulation. Personal Rights for 5 of 5 clients were signed and on file. P&I's are kept on a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingle and ledgers are current at this time.

Medications were centrally stored in a locked cabinet in the facility kitchen/office. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions. Centrally Stored Medication Records (CSMR) on 6/8/2023 were accurate for both clients in the facility.

LPA conducted a sample review of staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Andrea Jackson Administrator Certificate # 6020331735 is pending for renewal, at which time of effective will be administrator.

LPA reviewed Licensing Information System (LIS) with Administrator (pending certificate) who stated that is corrected and updated at this time other than Administrator; and would like to change facility emailing address information and added an alternate telephone number. Disaster drills are conducted quarterly with the last being 6/1/2023.

Deficiencies 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. Appeal Rights given.

LPA is requesting the following updated documents be submitted to CCL by 7/1/2023:

Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
	VISIT DATE: 06/08/2023

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	LIC 308 Designated LIC 500 Personnel Summary LIC 400 Affidavit Regarding Resident Cash Resources LIC 402 Surety Bond LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

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