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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801292
Report Date: 01/23/2024
Date Signed: 01/23/2024 01:12:49 PM

Document Has Been Signed on 01/23/2024 01:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CEDARS MICHELE CIRCLEFACILITY NUMBER:
216801292
ADMINISTRATOR:TAYLOR, ELIAFACILITY TYPE:
735
ADDRESS:101 MICHELE CIRCLETELEPHONE:
(415) 892-1610
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:House Manager, Elizabeth RamosTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. House Manager, Elizabeth Ramos arrived shortly after.

LPA and staff initiated a tour of the facility around 09:15 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 121 and 122 degrees F which are not within the range of 105 to 120 degrees F allowed per regulation. Maintenance is scheduled to come out to facility during the day of inspection and will be slightly turning down the water heater in order to get within the range allowed per regulation.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the garage. Personal Protective Equipment is stored in the office.

Fire extinguishers were last serviced February 2023. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 01/05/2024. Client cash resources were reviewed. Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrative Certificate for Administrator, Maria Lepe (6061120735) expired on 11/29/2023 but is on the departments pending list awaiting renewal.


Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CEDARS MICHELE CIRCLE
FACILITY NUMBER: 216801292
VISIT DATE: 01/23/2024
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Continued from LIC809

Medications and medication records were reviewed. During medication review, LPA observed that dates and prescription numbers on the centrally stored medication log for Client 1 (C1) were written incorrectly. Per conversation with House Manager, there was a change in pharmacies in order to receive an order for Levothyroxine in a daily medication sachet rather than a bottle. When this order was received, facility staff stopped giving the medication from the bottle in order to ensure that the dates on the sachet matched up with the dates the medication was given. At the time of visit, House Manager hadn't yet put the new prescription on the centrally stored medication log to reflect that the medication was being given out of the sachet rather than the bottle which it was previously being given from.

No deficiencies cited during inspection.

Exit interview conducted. Copy of report, LIC 811 (Confidential Names) discussed and provided to House Manager. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 02/23/2024:

LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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