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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 03/24/2023
Date Signed: 03/24/2023 01:39:13 PM


Document Has Been Signed on 03/24/2023 01:39 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 TERRACEFACILITY NUMBER:
216801028
ADMINISTRATOR:RICARDO ROMEROFACILITY TYPE:
740
ADDRESS:275 LOS RANCHITOS ROADTELEPHONE:
(415) 491-1935
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:130CENSUS: DATE:
03/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator/Executive Director, Ricardo RomeroTIME COMPLETED:
10:30 AM
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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Ricardo Romero. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

LPA reviewed the following reports with Executive Director:
Death Report: CCL received a death report on 03/01/2023. The report states that on 2/22/2023, Resident 1 (R1) was found unresponsive by care staff. Per report, R1 was not on hospice, but had a decline in health after their last visit to the hospital. Facility made all appropriate notifications per regulation.
LPA discussed R1 with Executive Director. Per conversation with Executive Director, R1 resided in Assisted Living but was very independent. Prior to their death, R1 was observed to be happy, but had a rapid decline in overall mobility and health. Executive Director stated that the Coroner reported to the facility that R1's death was from natural causes. Facility will be submitting a copy of R1's Death Certificate to CCL when it is available.

Incident Report: CCL received an incident report on 03/03/2023. The report states that on 02/25/2023, Resident 2 (R2) expressed to staff that they were having a difficult time mentally. Report also states that R2 wanted to kill themselves. Facility made all appropriate notifications per regulation.
LPA discussed R2 with Executive Director. Per conversation with Executive Director, R2's spouse had a decline in health and R2 was having a difficult time. Facility provided a one-on-one companion for R2, social worker support, and chaplain services. Facility and family discussed updating R2's care plan to include scheduled checks. As of 3/24/2023, R2 is continuing to be on frequent checks. Facility has continued to work with R2's family and the chaplain to provide additional support and services.

LPA conducted a walkthrough with Executive Director/Administrator.

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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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