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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:20:14 PM


Document Has Been Signed on 04/25/2023 02:20 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: 125DATE:
04/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Assisted Living Director, Mary Ann De Lara, and Resident Relations Director, Arlene SamonteTIME COMPLETED:
01:45 PM
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At approximately 1:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Assisted Living Director, Mary Ann De Lara, and Resident Relations Director, Arlene Samonte. Executive Director/Administrator, Ricardo Romero, was available by telephone. The purpose of the visit was to follow up on a self-reported incident that were submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 04/05/2023. Report states that on 03/28/2023, Resident 1 (R1) was taken to the hospital due to not having a bowel movement. Facility made all appropriate notifications per regulation.

LPA, Assisted Living Director, and Resident Relations Director discussed R1. Facility had been communicating with R1's Physician and Responsible Party regarding observed changes with R1. As of today, 04/25/2023, R1 has not been observed to have issues relating to their bowel movements. Facility has continued to communicate with R1's Responsible Party and Physician to provide appropriate care needs for R1.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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