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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803493
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:11:22 PM

Document Has Been Signed on 03/08/2022 03:11 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:CH&S LIFE COLLEGEFACILITY NUMBER:
216803493
ADMINISTRATOR:ABATE, CHASFACILITY TYPE:
775
ADDRESS:837 SWEETSER STREETTELEPHONE:
(415) 897-8676
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 18CENSUS: 14DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer Harter - Program ManagerTIME COMPLETED:
11:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Jennifer who contacted licensee. Licensee Chas Abate arrived during the visit. There were 14 clients present at the facility today. Facility has 15 clients enrolled in the program at this time. Facility has different activities been offered throughout of the day including outings.

LPA toured the facility on 3/8/2022 with staff Jennifer. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured building and grounds, day activity rooms, kitchen, and bathrooms. Carbon monoxide was tested and is properly operating. Smoke Detectors were inspected, and facility had properly operational smoke detectors available. Facility has a pullout fire station, however; facility stated that they don’t have proof that it is checked annually; usually no one unless facility requests from Fire Department or company comes out to test. Department is advising facility to keep a log of when fire pullout station is tested. Fire extinguisher was last charge on 10/2018. (see LIC 809-D) Clients have their own transportation. Facility does not transport clients at this time. Toxins, chemicals and hazardous items are safely stored in a locked cabinet in a kitchen cabinet. During the visit kitchen cabinet under sink had several unlocked toxins. Clients have access to unlocked kitchen in the facility during day program (see LIC 809-D) Bathrooms were all equipped with soap dispensers and individual paper towels. Facility understands that hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms. Clients provide their own snacks and lunches, but program will supply food for special occasions. There is one refrigerator available for client food. Facility doesn’t administer medications or handles P&I.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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 8
Document Has Been Signed on 03/08/2022 03:11 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 03/08/2022 at 11:35 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: CH&S LIFE COLLEGE
FACILITY NUMBER: 216803493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,record review, the licensee did not comply with the section cited above in 1 out of 1 fire extinguesher which poses/posed a potential health, safety or personal rights risk to persons in care. Facility fire extinguisher was last charge on 10/2018. (see pic) Facility didn't comply with State Fire Marshal requirements.
POC Due Date: 03/22/2022
Plan of Correction
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Facility to ensure that fire extingueshers are checked and charged annually. Facility agrees to have fire extinguesher charged and submit proof of service to Department by POC due date of 3/22/2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CH&S LIFE COLLEGE
FACILITY NUMBER: 216803493
VISIT DATE: 03/08/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance. Facility has hand sanitizer available for visitors, staff, and clients. Staff and clients before coming into facility have temperature checked and logged. Facility has PPE supply stored in the office facility. There has been no new staff hired and/or new clients admitted since COVID. Clients wear masks when inside the facility per program manager. All staff had masks on during this visit. Staff have had all PPE training required on file and is working towards acquiring N-95 fit testing per staff program manager. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills was last conducted on 10/2021 and facility understands that disaster drills must be conducted at least every 6 months.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 3/15/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 03/08/2022 03:11 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 03/08/2022 at 11:35 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: CH&S LIFE COLLEGE
FACILITY NUMBER: 216803493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which 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 observation and interview, the licensee did not comply with the section cited above in 1 out of 2 cabinets for toxins which poses an immediate health, safety or personal rights risk to persons in care. LPA during tour of the facility observed a cabinet under the kitchen sink with several unlocked toxins. Clients have access to the kitchen during day program (see pic)
POC Due Date: 03/09/2022
Plan of Correction
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Facility to ensure that all toxins and other dangers items are locked and not accessible to clients. Facility agress to lock all toxins in an appropriated locked cabinet and/or lock cabinet under the kitchen sink. Facility to submit self certification that all toxins and items that might constitute danger for clients in care have been locked by POC date of 3/9/2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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