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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 03/02/2022
Date Signed: 03/02/2022 10:30:30 AM


Document Has Been Signed on 03/02/2022 10:30 AM - 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 TERRACEFACILITY NUMBER:
216801028
ADMINISTRATOR:RICARDO ROMEROFACILITY TYPE:
740
ADDRESS:275 LOS RANCHITOS ROADTELEPHONE:
(415) 491-1935
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:130CENSUS: 117DATE:
03/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Ricardo RomeroTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Drake Terrace for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA was met by Administrator, Ricardo Romero, and was granted access into the facility.

CCL received an incident report reporting a medication error. The error occurred on 02/15/2022 while trainee was dispensing medication. R1 was given the wrong prescribed medication during medication passing. R1 and R2 were sitting together and both had the same first name, medication error was observed on 2/15/2022 by S1. Responsible party and prescribing doctor were notified of medication error. LPA obtained copies of the in-house incident report indicating a medication error along with the Medication Assessment Record (MAR) for the month of February 2022 for R1.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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 2


Document Has Been Signed on 03/02/2022 10:30 AM - 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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2022
Section Cited

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87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.

This requirement is not met as evidenced by:
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Based on record review and interview with Administrator the facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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