216801028-1-6-2025-21-AS-CFES-DCNUXD-20250106145810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 01/06/2025
Date Signed: 01/06/2025 02:58:20 PM

Document Has Been Signed on 01/06/2025 02:58 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:	DRAKE TERRACE		FACILITY NUMBER:	216801028
ADMINISTRATOR/ DIRECTOR:	SHAWN MOONEY		FACILITY TYPE:	740
ADDRESS:	275 LOS RANCHITOS ROAD		TELEPHONE:	(415) 491-1935
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 130	TOTAL ENROLLED CHILDREN: 0	CENSUS: 115	DATE:	01/06/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Executive Director/Administrator, Shawn Mooney		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 9:05AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Shawn Mooney, and Assisted Living Director, Tess Estilo. 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, LPAs was informed that there were 92 residents in Assisted Living and Memory Care with 23 Independent Living residents for a total of 115 residents in care. LPAs was also informed that there were 34 staff members on-site. At approximately 9:45AM, LPAs reviewed Facility Staff Roster with Executive Director and Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed resident files and resident medication. Files were all found to be well organized, thorough and contained the required documentation. During medication review, LPAs observed that 2 of 8 resident medications were not documented on the log as required. Review of facility's log indicated that facility understands how to document medications appropriately. Discussion with Executive Director indicated that they are audited by their pharmacy monthly (technical assistance issued, LIC9102, regulation 87465(h)(6)). LPAs also followed up on incident reports that were self-submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report and SOC341 on 03/06/2024. Reports state that on 02/29/2024, Resident 1's (R1) family notified facility management of unusual transactions on their joint financial account. R1's family also reported that $40 were missing from R1's wallet. Facility made all appropriate notifications per regulation. Incident Report 2: CCL received an incident report on 03/07/2024. Report states that on 02/29/2024, facility medication technician observed that Resident 2 (R2's) prescribed medication was discontinued on their electronic medication authorization record (EMAR) and that facility did not have a copy of the discontinued medication. Report continues to state that facility verified R2's medication list, and R2 received a new order for their medication on 03/01/2024. Facility made all appropriate notifications per regulation. Continued on LIC809C

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Caitlynn Felias	TELEPHONE: 707-588-5039
	DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DRAKE TERRACE	FACILITY NUMBER: 216801028
	VISIT DATE: 01/06/2025

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Continued from LIC809
Incident Report 3: CCL received an incident report and SOC341 on 03/28/2024. Reports state that on 03/25/2024, Resident 3's (R3) financial adviser notified facility management of $120 and credit cards missing from R3's apartment. Facility made all appropriate notifications per regulation.

Incident Report 4: CCL received an incident report on 04/30/2024. Report states that on 04/29/2024, Resident 4 (R4) was given the wrong medication for pain. Facility made all appropriate notifications per regulation (deficiency cited, LIC809D, regulation 87465(a)(4)).

Incident Report 5: CCL received an incident report on 05/02/2024. Report states that on 05/01/2024, Resident 5 (R5) was being assisted by Staff Member 1 (S1). When S1 transferred R3 to their wheelchair, S1 pushed R5's foot rests on the wheelchair and hit R5 in their leg. R5 sustained a hematoma blister to their leg. On 05/02/2024, facility contacted emergency services for R3 to be further evaluated due to blister increasing in size. Facility made all appropriate notifications per regulation.

Incident Report 6: CCL received an incident report on 08/20/2024. Report states that on 08/19/2024, Resident 6 (R6) had an unwitnessed fall outside of the community on the sidewalk. R6 was observed to be bleeding from their head. Emergency services were contacted and R6 was taken to the hospital to be further evaluated. Facility made all appropriate notifications per regulation.

Incident Report 7: CCL received an incident report on 12/27/2024. Report states that on 12/18/2024, Resident 7 (R7) notified the front desk that they couldn't find their spouse, Resident 8 (R8). Per R7, they had left R8 with other residents of the community. Facility staff initiated their elopement protocol and R8 was found 300 feet away from the property. Report states that R8's wanderguard bracelet and alarmed doors were functioning appropriately. Report continues to state that facility conducted a care conference with R7 and R8's care plan was updated accordingly. Facility made all appropriate notifications per regulation. Review of R8's Physician's Report states that they are unable to leave the facility unassisted. (deficiency cited, LIC809D, regulation 87468.2(a)(4)).

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 (Deficiency Page), Confidential Names (LIC811), Plan of Corrections, Plan of Corrections Letter, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/06/2025 02:58 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 01/06/2025 at 02:18 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: DRAKE TERRACE	FACILITY NUMBER: 216801028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.2(a)(4)

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee did not comply with the section cited above. Licensee did not ensure that R8 was supervised as required resulting in R8 eloping from the facility. Review of R8's physician report states that they are unable to leave the facility unassisted. This is an immediate health and safety risk to residents in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	Licensee to schedule training for all care staff reviewing elopement procedures. Licensee to provide scheduled training date to CCL by POC due date of 01/07/2025. Training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. Training to be submitted to CCL by POC due date of 01/16/2025.

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee did not comply with the section cited above and did not ensure that Resident 4's medication was administered correctly as required. Incident Report stated that R4 was given an incorrect "as needed" medication for pain. This is an immediate health and safety risk to residents in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	Licensee conducted training for S1 and all medication technicians on 05/01/2024. Training documentation provided to LPAs during visit on 01/06/2025. Deficiency cleared during visit.

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

TELEPHONE: (707) 588-5059

LICENSING EVALUATOR NAME:

Caitlynn Felias

TELEPHONE: 707-588-5039

LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

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