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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803488
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:01:24 AM

Document Has Been Signed on 12/08/2022 11:01 AM - 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:CASA RENE SOCIAL REHABFACILITY NUMBER:
216803488
ADMINISTRATOR:HAINBUCH, STEFEN ROQUEFACILITY TYPE:
772
ADDRESS:1109 SIR FRANCIS DRAKE BLVDTELEPHONE:
(415) 419-6900
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 10CENSUS: 5DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Case Manager Tina StanfordTIME COMPLETED:
11:10 AM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1-year Infection Control visit of the facility. LPA was welcomed by Case Manager Tina Stanford, LPA spoke via phone to Interim Administrator Connie Mann. There are 5 clients currently 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 113.3 degrees F and 114 degrees F within Title 22 regulations of 105 degrees to 120 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 drawer in staff office area. 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. last tested 11/29/2022. Fire extinguisher was found to be last charged on 11/30/2022.

Infection Controle:

Facility has submitted a Mitigation Program and Infection Control Plan. 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 had PPE training and have been N95 Fit Tested.


Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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 2
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: CASA RENE SOCIAL REHAB
FACILITY NUMBER: 216803488
VISIT DATE: 12/08/2022
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Disaster Drills are conducted monthly with the last being 09/30/2022.

LPA reviewed Licensing Information System (LIS) with Case Mgr. who stated Interim Administrator and email needs to be changed. Once LPA receives documents from Interim Administrator they will be updated in 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.

No deficiencies cited during today’s inspected.


LPA Hansen is requesting Licensee to update and submit the following documents by 12/23/2022 to SRRO:

LIC308-Designation of Facility Responsibility
LIC400-Affidavit Regarding Client/Resident Cash Resources
& Surety Bond
Copy of Current Administrator Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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