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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 02/03/2023
Date Signed: 02/03/2023 11:52:06 AM


Document Has Been Signed on 02/03/2023 11:52 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: 90DATE:
02/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, RIcardo RomeroTIME COMPLETED:
12:00 PM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies Visit and met with the front desk receptionist. Resident Relations Director, Arlene Samonte (AS), arrived later during visit at approximately 9:15AM. Executive Director/Administrator, Ricardo Romero, arrived later during visit at approximately 10:00AM. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

LPA conducted a walkthrough with Resident Relations Director and Executive Director/Administrator.

LPA and Executive Director discussed the following:
  • Covid and Influenza A Protocols
  • Staffing
  • Incident Reports


LPA reviewed the following reports with Executive Director:

Incident Report 1: CCL received an incident report on 10/4/2022. Report states that on 9/26/2022, Resident 1 (R1) was found on the floor. Resident was observed to be unable to verbalize the event and only say their name. Facility called Emergency Personnel to evaluate and R1 was sent to the hospital. Facility made all appropriate notifications per regulation.

LPA and Executive Director discussed R1. As of 2/3/2023, R1 has since moved out of the facility due to changing care needs.

Continued on LIC 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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: 02/03/2023
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Continued from LIC 809

Incident Report 2: CCL received an incident report on 12/30/2022. Incident report states that on 12/19/2022, Resident 2 (R2) was taken to the hospital by family after attending an appointment. Facility made all appropriate notifications per regulation.

LPA and Executive Director discussed R2. As of 2/3/2023, Facility has been monitoring R2 appropriately.

Incident Report 3: CCL received an incident report on 12/6/2022. The report states that on 11/30/2022, Resident 3 (R3) was given an incorrect amount of medication. Facility contacted R3's Physician and followed Physician guidance provided. Facility made all appropriate notifications per regulation.

LPA and Executive Director discussed R3. Facility submitted In-Service Training for all staff who handle medications on 12/6/2022.

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.

*Facility submitted Medication Training and training documents to CCL on 12/6/2022. Deficiency cited on 2/3/2023 has been cleared during this visit.*

Exit interview conducted. Copy of report, LIC-809D, LIC9102 (Technical Violation), LIC 811 (Confidential Names), Plan of Corrections, Appeal Rights, and Plan of Corrections Letter, discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2023 11:52 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: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited

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87465 Incidental Medical and Dental Care (a) (a) A plan for incidental medical and dental care shall be developed...encourage routine medical and dental care... by compliance with the following: (5)Facility staff...may assist persons with self-administration as needed. This requirement was not met as evidenced by: Based on the incident report received, the
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Facility submitted Medication Inservice Training with Staff names and signatures as well as Training Documents on 12/6/2022. Deficiency has been cleared during visit.
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Licensee did not comply with the section cited above, and did not administer medication to Resident as prescribed by their physician. This poses an immediate health and safety risk to residents 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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