216803488-12-13-2021-21-AS-SHAN-C9P2LU-20211213163009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803488
Report Date: 12/10/2021
Date Signed: 12/13/2021 04:30:26 PM

Document Has Been Signed on 12/13/2021 04:30 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	CASA RENE SOCIAL REHAB		FACILITY NUMBER:	216803488
ADMINISTRATOR:	HAINBUCH, STEFEN ROQUE		FACILITY TYPE:	772
ADDRESS:	1109 SIR FRANCIS DRAKE BLVD		TELEPHONE:	4152569995
CITY:	KENTFIELD	STATE: CA	ZIP CODE:	94904
CAPACITY: 10		CENSUS: 5	DATE:	12/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Stefen Hainbuch, Administrator		TIME COMPLETED:	02:20 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year visit of the facility. LPA was welcomed by Administrator - Stefen Hainbuch, MA. There are 5 clients at the facility. The facility has six client bedrooms. Random bedrooms were inspected. There are two bathrooms for clients that were inspected. The hot water temperature in client’s bathrooms measured at 106.7 degrees F and 107 degrees F. Toxic cleaning supplies are stored in a locked closet located in the laundry room. Perishable and nonperishable food supplies were sufficient to Title 22 Regulations of 2 days of perishable and 7 days of nonperishable. Knives are kept locked in kitchen drawer. The kitchen and dining area was organized and free of clutter. The facility is well lit with a comfortable ambient temperature. The facility was clean and well maintained. There is a large multipurpose room used for client meeting and activities. A large seating area where clients may congregate, or staff are able to hold group meetings is located off the kitchen/dining area. The facility has a locked medication room. Medications are stored in a locked cabinet within the room. There is also a metal locked box stored within the medication cabinet for any medication that requires a third lock. The Facility has a multi pull station fire alarm with audible/visual notification. Facility has fourteen integrated carbon monoxide/smoke alarms and sprinklers are tested annually by A.S.T.I Services Inc. Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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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Document Has Been Signed on 12/13/2021 04:30 PM - It Cannot Be Edited

Created By: Shannan Hansen On 12/10/2021 at 01:41 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CASA RENE SOCIAL REHAB	FACILITY NUMBER: 216803488
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81019(e)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	As evidence by Based on observation,interview, and record review of todays annual inspection the licensee did not comply with the section cited above in 5 out of 14 staff not being cleared and or associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. On12/10/21 LPA learned that staff S1 through S5 has been working in the facility and according with records on Guardian is not fingerprint cleared and not associated to facility at this time.
	POC Due Date: 12/13/2021
	Plan of Correction
1 2 3 4	Facility administrator understands that staff must be fingerprint cleared & associated to the facility before working at facility. Facility administrator to submit a self certification that all staff working at the facility are fingerprint cleared & associated to facility before starting to work which should be submitted to Department by POC date of 12/13/21 is order to clear this citation. (civil penalty) Facility provided forms for association at the end of the visit.

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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Shannan Hansen

LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CASA RENE SOCIAL REHAB	FACILITY NUMBER: 216803488
	VISIT DATE: 12/10/2021

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Infection Controle:

Facility has submitted a mitigation program plan that has been approved. All staff, clients, & visitors check in with the electronic temperature log and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Clients come from CSU and are tested for COVID (must be negative) before coming to facility but are only at facility for a maximum of 21 days and or in an emergency 28 days. Posters have been placed at facility. Facility has PPE supply stored in a locked closet adjacent to the front desk and in a drawer at the front desk. Staff have not had PPE training and have not been N95 Fit Tested. Administrator will be getting this taken care of soon.

Disaster Drills are conducted monthly with the last being 11/3/2021.

LPA reviewed Licensing Information System (LIS) with Administrator who stated mobile number and email has been changed. LPA will get changed at office. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA discussed and provided a copy of new PIN 21-44 that went into effect Nov. 30, 2021 regarding all staff needing to be fully vaccinated or have exemption letter on file with results of their weekly surveillance testing.

LPA requested to review staff vaccination records but facility was unable to provide documentation. LPA gave TA for violation and informed Administrator of new PIN 21-44.

LPA arrived at facility to find Staff 1 (S1) working who was not fingerprint cleared. Staff 1 was asked to leave until facility receives clearance and is associated to facility. After further review LPA found S2, S3, S4, and S5 also not fingerprint cleared but had been working in the facility.

A Civil Penalty was assessed for $500.00 for staff not being fingerprint cleared.

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.

LPA Hansen is requesting Licensee to update and submit the following documents by 12/17/2021 to RPRO:

LIC308-Designation of Facility Responsibility
LIC400-Affidavit Regarding Client/Resident Cash Resources
Copy of Current Administrator Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

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