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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:45:51 PM

Document Has Been Signed on 12/17/2021 02:45 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:DUNA JOSON (AGSALOG)FACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 5DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michelle Tootle - Manager of Program OperationsTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and was welcome by Antoniette M. and Michelle M. Michelle Tootle - Manager of Program Operations was contacted and arrived during this visit. The purpose of the case management visit is to obtain additional information regarding incident report submitted to the Department.

Department learned that on 11/27/2021 client C1 left the facility unassisted and was found at neighbors house who then contacted facility regarding client C1 been founded in their bathroom. Staff S1 at the facility as per incident report "clients were eating breakfast while S1 prepared AM medication; while S1 assisted another client the doorbell rang and informed that C1 was at their house." Client C1 physician's report dated 6/29/21 states that client has a diagnosis of developmental delay & Autism with limited verbalization, and C1 not allowed to leave facility unassisted.(see copies, LIC 809-D) LPA asked questions and requested more information regarding facility procedures for clients that are not able to leave facility unassisted. Per staff, facility has awake staff 24 hrs/ 7 days a week. In addition, client C1

Department is requesting an updated LIC 500 to be submitted to CCLD by 12/20/21 at noon.

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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 12/17/2021 02:45 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 12/17/2021 at 02:10 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SAN LUIS HOUSE
FACILITY NUMBER: 216800881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2021
Section Cited
CCR
80078(a)

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80078(a)Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement isn't met as evidenced by: Based on
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Facility agrees to conduct staff training regarding elopment, wandering behaviors & C1 careplan and plan activities. Proof of staff training w/participants signature, trainer signature, what was
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interivew & records review facility staff didn't comply w/this section for 1of1 client which poses an immediate Health, Safety risk to residents in care.Client C1 eloped & was found at neighbors home(see copies)
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covered, & date of training to be submitted to CCL by 12/31/21. Facility to submit self certification that clients will be supervised & kept safe by POC date 12/18/21.

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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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
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