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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803136
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:22:24 PM

Document Has Been Signed on 07/11/2024 01:22 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:LIFE CONNECTION-DEVON HOMEFACILITY NUMBER:
216803136
ADMINISTRATOR/
DIRECTOR:		ZHU, SHERRYFACILITY TYPE:
735
ADDRESS:371 DEVON DRIVETELEPHONE:
(415) 350-6636
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff Member, Johnnie Reid, and Administrator, Sherry ZhuTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Johnnie "JJ" Reid. Administrator, Sherry Zhu, arrived at approximately 9:55AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 6 Ambulatory Clients with a total capacity of 6 clients. Upon arrival, LPA was informed that there were 6 clients in care, with 5 clients out of the community attending Day Program. LPA was also informed that there were 2 staff members on site.

At approximately 9:15AM, 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 9:20AM, LPA conducted a walk-though of the facility with Staff Member. 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 one story building with 3 Client bedrooms, 1 staff room, 2 bathrooms, and common spaces. Facility does not have an Infection Control plan on file. Review of documents at the facility showed that the facility had their mitigation plan for Covid-19 but had not yet submitted their Infection Control Plan as required (see deficiency, LIC809D, regulation 85075.5(c)). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 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 2 of 3 facility sinks were found to be out of compliance with Title 22 Regulations of 105 to 120 degrees Fahrenheit, measuring between at 123.6F and 124.8F Per conversation with Staff Member and Administrator, they have been in contact with a vendor to fix their boiler. LPA reviewed email correspondence between facility and vendor and reviewed facility's water temperature logs which showed that facility's temperatures were within Title 22 Regulations as of 07/03/2024 (see Technical Violation, LIC9102, regulation 80088(e)(1)). During walkthrough, LPA observed the following toxins and hazards to be accessible: unlocked knife drawer and unlocked toxins cabinet in the kitchen (deficiency cited, see LIC809D, regulation 80087(g)). Fire extinguishers were last inspected May 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted in May 2024.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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: LIFE CONNECTION-DEVON HOME
FACILITY NUMBER: 216803136
VISIT DATE: 07/11/2024
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Continued from LIC809

LPA reviewed staff files, client files, client medication, and client P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. During medication review, LPA observed that the facility uses a written Medication Authorization Record (MAR) and a centrally stored log. LPA observed that some medications were documented incorrectly. LPA and Administrator discussed utilizing their Pharmacy's centrally stored log to ensure accuracy (see Technical Violation, LIC9102, regulation 80075(k)(7).

Administrator's Certificate for Xiaotony (Sherry) Zhu (7034101735) is current with an expiration date of 04/18/2025.

LPA requested the following documents to update facility file:

  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Surety Bond (LIC 402)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 8/11/2023.

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, LIC809D, LIC9102 (Technical Violation/Advisory), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2024 01:22 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/11/2024 at 12:46 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: LIFE CONNECTION-DEVON HOME
FACILITY NUMBER: 216803136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observations, Licensee did not comply with the section cited above. LPA observed an unlocked knife drawer and unlocked toxins cabinet in the kitchen. LPA observed facility staff immediately lock the drawer and cabinet. This poses/posed a potential health and safety risk to clients in care.
POC Due Date: 07/21/2024
Plan of Correction
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Licensee to submit In-Service Training reviewing regulation and how to ensure toxins and hazards are kept inaccessible to clients in care. In-service training to include the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 07/21/2024.
Type B
Section Cited
CCR
85095.5(c)
85095.5 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on document review, Licensee did not comply with the section cited above. LPA observed that facility has not submitted an Infection Control Plan as required. This poses/posed a potential health and safety risk to clients in care.
POC Due Date: 07/21/2024
Plan of Correction
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Licensee to submit facility's Infection Control Plan by POC due date of 07/21/2024.
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:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


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