216800881-12-21-2023-21-AS-HRUS-CYQVM5-20231221153257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:33:07 PM

Document Has Been Signed on 12/21/2023 03:33 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:	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: 6	DATE:	12/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Manger of Program Operations- Kayla Hotchkiss, House Manager- Brittany Brown, Administrator- Andrea Jackson		TIME COMPLETED:	03:45 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 9:10 AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a Case Management Inspection on Incident Reports received by Community Care Licensing (CCL) on 10/23/2023, 11/02/2023, 12/01/2023, 12/07/2023,12/08/2023, 12/12/2023,12/19/2023, 12/20/2023 and 12/21/2023. LPA was greeted by staff, and discussed the purpose of the visit. Manager of Program Operations, Kayla Hotchkiss, arrived at approximately 11AM. House manager, Brittany Brown arrived at approximately 11:25AM, and Administrator, Andrea Jackson arrived at approximately 12:30PM. LPA observed there were 2 staff on shift, 4 clients in the house, and 2 clients at day program at the time of visit. Incident Report #1 received on 10/23/2023: Staff heard a loud thud followed by a scream from Client #1 (C1). Staff observed C1 to be laying on their left side and C1 refused to get up with help from staff. C1 got up after a couple minutes and took a few steps and fell to the floor. Staff noticed C1's arm hanging unusually and called 911 as staff suspected it to be broken. C1 was transported by paramedics to the hospital for treatment. C1 was diagnosed with a closed fracture of shaft of left humerus. Per conversation with Manager of Program Operations, C1 was also observed to have their feet tangled in their sheets, and that although C1 has an unusual gait it was unusual at the time for C1 to fall. The hospital wrapped their arm and put a sling on and returned them to the facility without pain medications. Upcoming appointments for further treatment were to be determined at the time of hospital visit. Facility got a prescription for pain medication for C1. Continued on LIC809C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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 4

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
	VISIT DATE: 12/21/2023

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

Continued from LIC809
Incident Report #2 received on 11/02/2023: C1 had been recovering from the fracture of shaft of left humerus when staff noticed that the left arm looked disfigured and was in need of immediate medical attention. Staff took C1 to the hospital where they were admitted and then scheduled for surgery the following day.
Per conversation with Manager of Program Operations, there was an upcoming appointment for C1 to receive surgery on their broken arm. As staff noticed the arm to be disfigured, they decided to transport C1 to the hospital in order to receive prompt medical attention and to get in sooner for surgery. C1 had surgery on Thursday 11/02/2023 and was discharged from the hospital on Sunday 11/05/2023. C1 was not required to wear a cast and was not in need of pain medication after a few days.

Incident Report #3 received on 12/01/2023: C1 had a bruise above their right eyebrow and below their right eye. Staff transported C1 to hospital for an evaluation. Staff had been interviewed by Associate Executive Director, Jim Rosetti to determine the cause of injury. Incident report states: "Cornerstone will review its training protocol and procedures for proper supervision of clients and observation strategies to prevent further incidents.". Training was conducted with all staff and consisted of the following topics:
- Identifying client needs
- Identifying potential hazards
- Performing daily body/ skin checks
-Properly responding to emergencies

Facility never was able to confirm what the cause of injury was to C1's eye area. Staff confirmed that there was an outing but there were not any observed falls. Although, staff confirmed that C1 tends to move with their head first and staff has seen C1 bump into things before. Staff claimed that their usual bumps were never severe enough to cause injury.
Client was transported to the hospital on 11/30/2023 to make sure they did not have a head injury. Hospital staff gave C1 multiple sedatives in order to perform a head scan which may have impaired C1s ability to ambulate. Facility staff had concerns about bringing C1 home at this time due to being uncertain whether C1 was having difficulty ambulating due to the sedatives or the possibility of a head injury. Imaging done at the hospital revealed that there was no internal injury to the head. Client was not discharged by hospital on 12/01/2023, however they did release C1 back into the care of facility personnel.
Continued on LIC809C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
	VISIT DATE: 12/21/2023

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

Continued from LIC809C

Incident Report #4 received on 12/07/2023: C1 was immediately brought back to hospital on 12/01/2023. C1 had not yet been officially discharged due to C1 being a fall risk and not being able to walk on their own. Hospital gave instructions that upon C1's discharge back into facility, C1 would need constant help from staff to assist with walking.

As mentioned above, C1 was released from hospital on 12/01/2023. Per conversation with Manager of Program Operations, C1 was brought out by hospital personnel to the facility van. During the same day, hospital staff called facility and stated they were looking for C1. Hospital requested that facility bring C1 back to hospital as they were not stable enough to return to the facility.

Incident Report #5 received on 12/08/2023: C1 was evaluated by a physical therapist while they were in the hospital. The physical therapist stated that C1 was still a fall risk due to balance issues.

Per conversation with Manager of Program Operations, PT recommended that C1 does not ambulate on their own. Nursing staff administered sedatives to C1 while in the hospital without a Direct Support Professional (DSP). When DSPs were not there, nursing staff would administer sedatives to keep C1 calm. Sedatives were prolonging C1s ability to ambulate.

As per conversation, Medi-cal would not continue to pay for C1s medical services due to C1 no longer meeting medical criteria, so they discharged them with assistance with ambulation. C1 was brought back to facility on Saturday 12/09/2023. GGRC is to provide Hearts of Humanity in order to keep C1 with a 1:1. In the meantime, facility is keeping a 1:1 with C1 to meet the needs of C1.

Incident Report #6 received on 12/12/2023: C1 was sitting on the couch with staff when Client #2 (C2) bit C1 on the left arm. Staff provided basic first aid on C1's arm.

As per conversation with Manager of Program Operations, these attacks appear to be unprovoked. C2 is calm when approaching C1. Staff believes that C2 targets C1 due to the size of C1, and that C1s vocalizations could be a trigger for C2.

Continued on LIC 809C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: SAN LUIS HOUSE	FACILITY NUMBER: 216800881
	VISIT DATE: 12/21/2023

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

Continued from LIC809C

Incident Report #7 received on 12/19/2023: C2 got up from the kitchen table to put their bowl into the sink. When walking back from the sink C2 grabbed C1 with both hands and bit their inner left forearm. Staff asked C2 to let go and they did as they were told. Staff reported that C2 did not appear to be agitated prior to this incident. C2 had a phone appointment with their Nurse Practitioner and there was an increase in their Quetiapine by 50mg in the mornings. Incident report states that C2's Primary Care Provider was contacted to do a health review to rule out any medical discomforts that may be increasing their behaviors.

Per conversation with Manager of Program Operations, the increase in medication did not improve the behaviors. The appointment with C2s Primary Care Provider is scheduled for 12/26/2023.

Incident Report #8 received on 12/20/2023: C2 became agitated and ran past staff into C1s room and bit them on the arm. Staff redirected C2 from C1's room. C2 is scheduled to have a second appointment for any medication adjustments or treatment plan. Staff noted that C2 was showing signs of pain in their abdomen.

Incident Report #9 received on 12/21/2023: Staff had reason to believe that C2 had an increase in their biting behaviors due to their abdominal pain, so staff transported C2 to the hospital to have them evaluated. C2 was diagnosed with anemia and had a prior diagnosis of constipation.

Per conversation with Adminstrator and House Manager, C2 was observed to have a bowel movement 48 hours prior to the incident. It is unknown at this time as to why C2 has had an increase in these behaviors. On the appointment on 12/26/2023, staff will be requesting a blood panel and stool sample to find the cause of their abdominal pain.

No deficiencies cited during todays visit.

Exit interview conducted. Copy of report, LIC811 (Confidential Names), discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4