216800990-6-6-2023-21-AS-SHAN-CSJQGK-20230606120940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800990
Report Date: 06/06/2023
Date Signed: 06/06/2023 12:09:50 PM

Document Has Been Signed on 06/06/2023 12:09 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:	QUALITY LIFESTYLE		FACILITY NUMBER:	216800990
ADMINISTRATOR:	MCPHERSON, FRANKE		FACILITY TYPE:	735
ADDRESS:	53 PLATA COURT		TELEPHONE:	(415) 899-9999
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 6		CENSUS: 5	DATE:	06/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Jim Lee, Licensee & Franke McPherson, Administrator		TIME COMPLETED:	12:15 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 Required inspection to this facility and met with Jim Lee, Licensee & Franke Gelotte, Administrator. 4 clients were leaving to attend day program and 1 stayed home with an injured ankle during the time of the visit. There are 5 clients at the facility. LPA toured the facility on 6/6/2023 at 8:15 AM with licensee Jim Lee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/27/2022 at the time of the visit. Smoke detectors & carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured 107.7 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in client’s bathroom while touring facility. 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 laundry room. Dangerous items were stored inaccessible to clients; although there was disinfectants located on kitchen windowsill at time of visit (see LIC 9102) and immediately locked up. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings. A review of five clients and a sample review of two staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 9:00 AM on 6/6/2023 and learned that 5 of 5 clients have had updated reappraisal/needs although do not have copies in files which Administrator stated GGRC has not provided (see LIC 9102) & care plan and physician’s report. P&I's are kept locked and are not co-mingled; facility responsible for 5 client’s P&I. LPA learned that 5 out of 5 client’s P&I ledgers are current. Continue LIC 809-C

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: QUALITY LIFESTYLE	FACILITY NUMBER: 216800990
	VISIT DATE: 06/06/2023

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

Medications were centrally stored in a locked medication cabinet in the facility kitchen. LPA conducted a sample review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions. In addition, Centrally Stored Medication Records (CSMR) were current for both clients in the facility.

LPA conducted a sample review of staff records at 9:30 AM on 6/6/2023 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of CPR & 1^st Aid certification for staff records that were reviewed, however; 2 out of 2 staff didn’t have a copy of active 1^st Aid on file. Administrator stated that they have been scheduled. (see LIC 9102 Advisory Notes) Frankie Gelotte Administrator Certificate # 6010372735 expired on 10/14/2022 but has resubmitted, certified mail receipt proof provided.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time other than Administrator’s name change that was previously submitted to CCL. Disaster Drills have been conducted every four months with the last one being conducted on 3/17/2023.

There were no deficiencies cited at this time.

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

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
Copy of Current Administrator's qualifications and Certificate

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4