216801291-2-8-2022-21-AS-CFGS-CBFR3A-20220208113938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 02/03/2022
Date Signed: 02/08/2022 11:39:52 AM

Document Has Been Signed on 02/08/2022 11:39 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:	CEDARS FERRIS DRIVE		FACILITY NUMBER:	216801291
ADMINISTRATOR:	ANDERSON, STACY		FACILITY TYPE:	735
ADDRESS:	1106 FERRIS DR.		TELEPHONE:	(415) 892-1208
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY: 6		CENSUS: 6	DATE:	02/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Vivian Lundy - staff		TIME COMPLETED:	03:45 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	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Vivian Lundy. Rob Robinson – Program Director Residential Services spoke with LPA on the phone. Some clients were present at the facility. Some clients at this facility are in day program and/or zoom activities. There are activities planned for clients during the day if they want to participate. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 2/3/2022 with staff Vivian facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 02/2021 at the time of the visit. Carbon monoxide detector was operational during visit. Sample test of Smoke detectors was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the garage, however; LPA observed Clorox and Ajax unlocked under sink of 2 different unlocked bathrooms and a kitchen cabinet unlocked with several toxins. As per staff, they don’t have a key to lock cabinet. (see LIC 809-D, see pictures) Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 131.7 degrees F and 133.3 degrees F in 3 out of 3 faucets falling out of Title 22 acceptable regulations of 105 to 120 degrees F. (see LIC 809-D) Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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 4

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: CEDARS FERRIS DRIVE	FACILITY NUMBER: 216801291
	VISIT DATE: 02/03/2022

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
26
27
28
29
30
31
32

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility, small table with hand sanitizer and other items designated for visitors are at entrance. Staff before coming into work has temperature checked. Facility has PPE supply stored in the garage. There has been new staff hired and no new clients since COVID-19. Clients’ medications are stored and locked in medication cabinet inside office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available zoom and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and staff had N-95 fit testing conducted.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Department is requesting Licensee to update the following documents and submit to CCL by 2/10/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/08/2022 11:39 AM - It Cannot Be Edited

Created By: Carla Fernandes-Goes On 02/03/2022 at 03:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CEDARS FERRIS DRIVE	FACILITY NUMBER: 216801291
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above several unlocked toxins which poses an immediate health, safety or personal rights risk to persons in care. LPA observed 1 clorox and 1 Ajax under an unlocked cabinet sink and several toxins in an unlocked kitchen cabinet. (see pictures)
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that all toxins and other items that could pose danger to clients in care will be locked at all times. Facility to lock all toxins and submit a self certification with pictures of locked toxins to CCL by POC date by 2/4/2022.

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 bathroom faucets which poses an immediate health, safety or personal rights risk to persons in care. Facility hot water temperature in clients' bathroom faucets measured between 131.7 degrees F and 133.3 degrees F.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that hot water temperature on client's faucets will maintain temperatures between 105 degrees F and no more than 120 degrees F. Facility to adjust hot water temperature and submit a self certification that water has been adjusted to CCL by 2/4/2022. In addition, facility to submit a 7 day hot water temperature log by 2/10/2022.

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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Carla Fernandes-Goes

LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4