<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803488
Report Date: 12/05/2023
Date Signed: 12/05/2023 02:27:35 PM

Document Has Been Signed on 12/05/2023 02:27 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:CASA RENE SOCIAL REHABFACILITY NUMBER:
216803488
ADMINISTRATOR:CONNIE MANNFACILITY TYPE:
772
ADDRESS:1109 SIR FRANCIS DRAKE BLVDTELEPHONE:
(415) 419-6900
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 10CENSUS: 9DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lead Case Manager, Tina StanfordTIME COMPLETED:
02:40 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 inspection of facility. LPA was welcomed by Case Manager Tina Stanford, LPA spoke via phone to new Program Director, Cederic Jackson who arrived during inspection. There are nine clients currently at the facility.

This social rehabilitation facility is a 28-day program designed to provide transition and stabilizing services to adult clients. Facility tour on 12/5/2023 began at 9:40 AM. Random bedrooms inspected had appropriate furnishings per Title 22 Regulations. There are two bathrooms for clients that were inspected. The hot water temperature in client’s bathrooms measured at 108.6 degrees F and 109.9 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 and at a comfortable temperature. The facility was clean and well maintained, with housecleaning service conducting once a month deep clean during inspection, during the month a sign up sheet is filled in by clients to complete and those not are done by staff. 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, although on todays visit the lock was not functioning. 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 the Greenbrae Fire Dept., last tested 10/2023. Fire extinguishers were found to be charged.
Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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
Document Has Been Signed on 12/05/2023 02:27 PM - It Cannot Be Edited


Created By: Shannan Hansen On 12/05/2023 at 02:01 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: CASA RENE SOCIAL REHAB
FACILITY NUMBER: 216803488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Program Director & record review, the licensee did not comply with the section cited above in 1 out of 9 clients TB tests results had not been given at time of admitance to facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Program Director to submit TB test results to CCL no later then POC due date of 12/8/2023 with written understaing of regulation.
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: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 12/05/2023
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
26
27
28
29
30
31
32
A review of nine clients & three staff records as well as two resident’s medications was conducted. LPA reviewed client’s files at 11:30 AM and learned that 9 out of 9 clients records were reviewed and found to be current' including: admission agreement; client rights; health assessment; care plan; although 1 out of the 9 clients at facility did not have TB test read & cleared as of yet (see LIC809-D).

LPA reviewed a sample of staff records at 12:45 PM and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2023 are on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed on 12/5/2023. The Medications of 2 out of 2 clients were found to be given according to physicians’ directions on 12/5/2023 at 1:30 PM. Centrally Stored Medications of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed Licensing Information System (LIS) with new Program Director Cedric Jackson, although the Regional Director is still Connie Mann, will need to change Program Director in system and mobile number. Disaster Drills are conducted monthly with the last being 11/28/2023.

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 1/5/2024 to SRRO:

LIC308-Designation of Facility Responsibility
LIC400-Affidavit Regarding Client/Resident Cash Resources
& Surety Bond
LIC500 Personnel Summary
LIC 9020 Register of Facility Client’s
Copy of Control of Property (Lease/Deed)
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4