216801028-10-3-2022-21-AS-CFES-CJUTTE-20221003150036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 10/03/2022
Date Signed: 10/03/2022 03:00:46 PM

Document Has Been Signed on 10/03/2022 03:00 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:	RICARDO ROMERO		FACILITY TYPE:	740
ADDRESS:	275 LOS RANCHITOS ROAD		TELEPHONE:	(415) 491-1935
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	130	CENSUS: 98	DATE:	10/03/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director, Ricardo Romero		TIME 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 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with the front desk receptionists. At 10:40AM, Resident Relations Director, Arlene Samonte, arrived and met with LPA. Executive Director, Ricardo Romero, arrived later during the visit at 11:05AM. The purpose of the visit was to follow up on three self-reported incidents that were submitted to Community Care Licensing (CCL) as well as review the current vaccination guidelines for Adult and Senior Care Living Communities. Incident Report 1: LPA spoke with Administrator regarding a report that was received by CCL on 9/16/2022. Incident report states that on 9/12/2022, Resident 1 (R1) reported to care staff that they were feeling dizzy. While care staff was taking their temperature, R1 fell and hit their head. Facility called 911 and R1 was sent to hospital to be evaluated. R1 returned to facility the next day with a diagnosis of Syncope. Facility made all appropriate notifications per regulation. LPA and Administrator discussed R1. As of 10/3/2022, R1 is still out of the community and is currently at a rehabilitation facility. Facility will be conducting a re-assessment of R1 once they return. Incident Report 2: LPA spoke with Administrator regarding a report and SOC-341 that was received by CCL on 9/26/2022. Incident Report states that on 9/17/2022, Resident 2 (R2) reported to the Assisted Living Director that a Medication Technician stole their jewelry - specifically a necklace. Executive Director spoke with R2 and was told a different story. During their conversation, R2 stated that they were not claiming that the Medication Technician stole their jewelry, but that they were being helped by care staff and it may have broke off or caught on someone's clothing. R2 also stated to Administrator that it was not the Medication Technician but the Caregiver that stole the jewelry. Facility conducted an internal investigation and thoroughly searched R2's apartment. Facility made all appropriate notifications per regulation. Continued on LIC-809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

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: 10/03/2022

NARRATIVE

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Continued from LIC809

LPA and Administrator discussed R2. LPA reviewed facility and resident documents, police report, and conducted interviews. LPA received a copy of the facility's Theft and Loss Policy. LPA reviewed the document and observed that Facility appropriately followed Policy Protocols as outlined in the document.

Incident Report 3: LPA spoke with Administrator regarding a report that was received by CCL on 10/03/2022. Incident report states that on 9/23/2022, Resident 3 (R3) called for assistance and was found on the floor in their bedroom by the responding care staff. Resident was observed to have bleeding on the side of their head. Facility called 911 and R3 was sent to the hospital to be evaluated. Facility made all appropriate notifications per regulation.

LPA and Administrator discussed R3. As of 10/3/2022, R3 is back at the community and returned on 9/23/2022. R3 has been observed to be doing well upon their return.

LPA conducted a walk-through of the facility with Executive Director. Facility's fire alarm system and combination smoke/carbon monoxide detectors are directly connected to the San Rafael Fire Department. Per Administrator, Facility's last fire drill was conducted 9/21/2022.

LPA and Administrator discussed PIN 22-05.2-ASC regarding current vaccine requirements needed for employees and residents.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC 811 (Confidential Names) 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: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

LIC809 (FAS) - (06/04)

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