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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803488
Report Date: 07/21/2022
Date Signed: 07/21/2022 10:15:52 AM

Document Has Been Signed on 07/21/2022 10:15 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:
4154196900
CITY:KENTFIELDSTATE: CAZIP CODE:
94904
CAPACITY: 10CENSUS: 7DATE:
07/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Director Liz McCannTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to review the circumstances surrounding an incident report submitted to Community Care Licensing. At the time of LPA's arrival, there were 7 clients & 3 staff including Elizabeth "Liz" McCann - Program Director of RSS and Casa Rene who LPA met with as Assistant Program Director (APD) Steven Hainbuch is covering a later shift.

The self-reported incident occurred on June 27, 2022 and involved a client receiving the wrong dosage of prescribed medication. Per doctor’s order C1 is to receive 500mg of medication in the am and 1000mg of medication in the pm. On 6/27/2022 S1 gave 1000mg in the am. Per the incident report, staff failed to review the dosage and client was over-medicated. The overdosage of medication was reported to Assistant Program Director, client was monitored and noted no adverse side effects reported. Consultation with county public health psych NP.

LPA reviewed the facility's "Medication Protocol" with Program Director. Additional safeguards and precautions have been put in place. Supervisor met with psych NP of county health to review incident. Staff is scheduled to attended refresher training on medication procedures through Relias and has been shadowed & shadowing during medication passes.

LPA is citing the facility for failure to assist a client with self-administration of prescription medications correctly.

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..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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 07/21/2022 10:15 AM - It Cannot Be Edited


Created By: Shannan Hansen On 07/21/2022 at 07:59 AM
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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
81075

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81075 Health-Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

***This requirement has not been met as evidenced by:
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Facility to provided document of when and what training is to be conducted by 7/22/2022 and provide proof of medical training for involved staff, to be completed with signed, dated documents after training by 7/26/2022. Program Director has put additional safety measures in place.
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...report that client took an incorrect dosage of their medication.

This is an immediate risk to the health and safety of clients in care.

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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: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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