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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:02:49 PM

Document Has Been Signed on 06/19/2024 03:02 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 HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR/
DIRECTOR:		KAYLA HOTCHKISSFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 525-1082
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 5DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Manager of Program Operations/ Administrator, Kayla HotchkissTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and follow up on an incident report that was received by Community Care Licensing (CCL) on 06/12/2024. LPAs were greeted by staff and discussed the purpose of the visit. Administrator, Kayla Hotchkiss arrived shortly after.

Upon arrival, LPAs observed HVAC repair services at the facility. LPAs and staff initiated a tour of the facility around 10 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 101 and 100 degrees F which are not within the range of 105 to 120 degrees F allowed per regulation. Administrator slightly turned up the water heater and will confirm with the LPA that the temperature has fallen into the range required as per regulation within 48 hours of inspection.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility had at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

Fire extinguishers were last serviced 04/29/2024. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 05/09/2024. Client cash resources were reviewed. Medications and medication records were reviewed. Five staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Administrative Certificate for Administrator, Kayla Hotchkiss (7032017735) expires 12/06/2025.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 06/19/2024
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Continued from LIC809

LPAs followed up on an incident report that was received by CCL on 06/12/2024: Incident report states that on 06/10/2024, staff were administering evening medications when they noticed that C2s Lurasidone HCL from the previous evening was still in the bubble pack. C2 did not have any adverse effects and continued the medication as prescribed. Facility has plans to conduct a medication training through their pharmacy.

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, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 07/19/2024:

LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2024 03:02 PM - It Cannot Be Edited


Created By: Helena Rummonds On 06/19/2024 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not administering clients medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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4
Facility has plans to complete a medication training through their pharmacy on 6/20/2024. Administrator agrees to send proof of medication training with staff sign in sheet by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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