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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801723
Report Date: 06/25/2024
Date Signed: 06/25/2024 12:15:50 PM

Document Has Been Signed on 06/25/2024 12:15 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:BEACON HILLFACILITY NUMBER:
216801723
ADMINISTRATOR/
DIRECTOR:		BENOIT, WILSONFACILITY TYPE:
735
ADDRESS:826 HAYDEN AVE.TELEPHONE:
(415) 897-9716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 4DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Wilson Benoit, and Licensee- Wally HyppoliteTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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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 Administrator, Wilson Benoit. LPA and Administrator discussed the purpose of the visit. Licensee, Wally Hyppolite arrived shortly after.

LPA and Administrator initiated a tour of the facility around 09:30 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 106 and 107 degrees F which are within the range of 105 to 120 degrees F allowed per regulation.

LPA observed the kitchen to be newly remodeled and in functioning condition. LPA observed cabinet under sink to be unlocked and contained various chemicals including Fabuloso, Clorox Bleach, and Pine Sol. LPA and Administrator discussed getting a magnet lock for underneath the sink. Upon entering the backyard, LPA observed a pair of closet doors that were in the process of being sanded and stained. LPA observed painters solvent and numerous paint cans outside due to various projects being done.

Extra hygiene products and linens were available. 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 room outside of kitchen.

Fire extinguishers were last serviced May 7, 2024. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 02/17/2024. Client cash resources were reviewed. Facility currently handles one clients cash resources. Remaining clients handle their own cash.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BEACON HILL
FACILITY NUMBER: 216801723
VISIT DATE: 06/25/2024
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Continued from LIC809

Five staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Administrator Certificate for Administrator, Wilson Benoit (6006356735) is up to date and expires 01/31/2025.

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.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 07/25/2024:

LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2024 12:15 PM - It Cannot Be Edited


Created By: Helena Rummonds On 06/25/2024 at 11:58 AM
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: BEACON HILL
FACILITY NUMBER: 216801723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above by having numerous toxins accessible to clients which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Adminstrator agrees to purchase a lock for storage of toxins underneath the kitchen sink. Administrator agrees to remove painters solvent, paint, and power tools from yard and keep them in a locked storage area. Photos to be submitted of new lock on kitchen cabinet and photos of yard with toxins removed to LPA by POC due date of 6/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024


LIC809 (FAS) - (06/04)
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