216801935-9-15-2023-21-AS-CFES-CVPUQN-20230915154724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801935
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:47:36 PM

Document Has Been Signed on 09/15/2023 03:47 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:	CAMBRIDGE HOUSE		FACILITY NUMBER:	216801935
ADMINISTRATOR:	LAKEDA BROWN-STEWARD		FACILITY TYPE:	735
ADDRESS:	1420 CAMBRIDGE STREET		TELEPHONE:	(415) 898-4262
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 6		CENSUS: 6	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Staff Member, Imani Lovings, and Manager of Program Operations, Kayla Hotchkiss		TIME COMPLETED:	03:55 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	At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Imani Lovings. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 6 clients in care, with all clients out of the community attending Day Program. LPA was also informed that there was 1 staff member on-site and that their shift was over at 9:30AM. The PM staff member arrives later in the afternoon when the Facility's clients return from Day Program. Staff Member contacted Kayla Hotchkiss, Manager of Program Operations, who arrived at the facility at approximately 10:35AM. At approximately 9:25AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:45AM, LPA conducted a walk-though of the facility with Manager of Program Operations. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Client bedrooms, 2 bathrooms, 1 staff office, common spaces, and an art room. Facility has a swimming pool on-site that has a perimeter and locked gate. Per conversation with Manager of Program Operations, clients do not use the pool unless there is staff supervision. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected December 2022. Facility's smoke detectors and carbon monoxide detectors were tested and operational. The last Fire Drill was conducted June 2023. At approximately 11:25PM, LPA reviewed staff files, client files, client medications, and P&I monies. Facility chooses to use a Medication Administration Record (MAR) to record when medications are being administered to clients. LPA observed that Staff and Client files were well organized and thorough. During Review, LPA observed that all clients did not have a Functional Capabilities Assessment (See Technical Violation, LIC9102, Regulation 80069(b)). Staff files had current First Aid and CPR certification. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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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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: CAMBRIDGE HOUSE	FACILITY NUMBER: 216801935
	VISIT DATE: 09/15/2023

NARRATIVE

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Continued from LIC809

During Medication Review, LPA observed Client 1 (C1) had a medication listed on the MAR that was to be given daily. This medication was observed to not have initials or be administered for multiple months. Review of C1's file does not show an active order or discontinued order for this medication. C1's most updated physician orders does not list this medication as a prescription. (See Technical Advisory, LIC9102, Regulation 80075(b)(5)(A)). LPA also observed Client 2 (C2) had a current and active medication that was not initialed or documented appropriately in the Facility's MAR. Review of documentation indicated that C2 has been taking this medication daily but facility staff have not been documenting that this medication has been given to C2 for the month of September 2023. Review of staff files indicated that facility staff had medication training conducted June 2023 (This Deficiency has been cited, see LIC809D, Regulation 80065(f)).
Client P&I Monies were found to be documented, secure and not commingled.

LPA also followed up on a self-reported incident that were submitted to Community Care Licensing (CCL).
Incident Report 1: CCL received an incident report on 07/07/2023. The report states that on 07/05/2023, facility staff were unable to access the locked medication cabinet in order to give Client 3 (C3) their scheduled medication. Facility contacted C3's physician for advice but did not receive a response. Facility contacted C3's pharmacy and followed their instructions regarding the missed dose. Facility made all appropriate notifications per regulation.

LPA discussed C3 with Manager of Program Operations. Per conversation with Manager of Program Operations, a new lock was purchased to ensure that this situation does not occur again. All staff also received training in July 2023 on how to open the new medication lock and steps to take if this situation occurs again. Facility to submit proof of Training to CCL by 09/25/2023.

LPA is requesting the following documents in order to update facility file:

Affidavit regarding Client/Resident Cash Resources (LIC400)
Designation of Facility Responsibility (LIC308)
Emergency Disaster Plan (LIC610D)
Updated Personnel Report (LIC500)
Surety Bond (LIC 402)
Register of Clients/Residents (LIC9020)

Facility Documents to be submitted to CCL by due date of Thursday, 10/15/2023.

Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2023 03:47 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 09/15/2023 at 03:08 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: CAMBRIDGE HOUSE	FACILITY NUMBER: 216801935
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(f)

80065 Personnel Requirements (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review and Observations made, the Licensee did not comply with the section cited above for 2 of 6 Client medication records and did not ensure that records were documented accurately. Staff Files reviewed indicated that Medication Training was conducted for all staff in June 2023. This poses a potential health, safety or personal rights risk to Clients in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Licensee to conduct an In-Service Training with all Direct Care Staff reviewing Medication Training and Proper Medication Documentation. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 09/25/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CAMBRIDGE HOUSE	FACILITY NUMBER: 216801935
	VISIT DATE: 09/15/2023

NARRATIVE

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Continued from LIC809C

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, LIC811 (Confidential Names), LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Manager of Program Operations. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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