216801028-12-20-2023-21-AS-CFES-CYQ22A-20231220160025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:00:33 PM

Document Has Been Signed on 12/20/2023 04:00 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:	DRAKE TERRACE		FACILITY NUMBER:	216801028
ADMINISTRATOR:	DONNA DANIEL-HERR		FACILITY TYPE:	740
ADDRESS:	275 LOS RANCHITOS ROAD		TELEPHONE:	(415) 491-1935
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	130	CENSUS: 115	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director, Donna Daniel-Herr, and Assisted Living Director, Mary Ann De Lara,		TIME COMPLETED:	04:15 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	At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Donna Daniel-Herr and Assisted Living Director, Mary Ann De Lara. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPA was informed that there were 93 residents in Assisted Living and Memory Care with 21 Independent Living residents for a total of 114 residents in care. LPA was also informed that there were 22 staff members on-site. At approximately 9:45AM, LPA reviewed Facility Staff Roster with Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:15AM, LPA conducted a walk-though of the facility with Assisted Living Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care, and has separate Independent Living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. At approximately 11:30AM, LPA reviewed 5 resident files and 5 staff files. Resident Files were all found to be well organized, thorough and contained the required documentation. LPA observed that 4 of 5 staff files were missing all or parts of the required annual training per Health and Safety Code (this deficiency has been cited, see LIC809D, Health and Safety Code 1569.625(b)(2)). Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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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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: DRAKE TERRACE	FACILITY NUMBER: 216801028
	VISIT DATE: 12/20/2023

NARRATIVE

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Continued from LIC809

Facility's fire extinguishers were last inspected April 2023. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected February 2023 and October 2023. Facility's last fire/disaster drill was conducted October 2023.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/20/2023 04:00 PM - It Cannot Be Edited

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: DRAKE TERRACE	FACILITY NUMBER: 216801028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review, the LIcensee did not comply with the section cited above. LPA observed 4 of 5 staff files did not have the annual trainings completed as required by the Health and Safety Code. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/30/2023
	Plan of Correction
1 2 3 4	Licensee to submit proof of completed required trainings for S2, S3, S4, and S5 by POC due date of 12/30/2023. Licensee to submit a step by step plan to ensure that all staff on site obtain their annual 20 hour training as required by Health and Safety Code by POC due date of 12/30/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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