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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:51:31 PM

Document Has Been Signed on 12/17/2021 01:51 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:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR:WILLIE RIVIOREFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 5CENSUS: 5DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Curtis Mixon - staffTIME COMPLETED:
11:48 AM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with Curtis Mixon - staff. Sheri Lott - supervisor wasn't able to arrive for this visit, however; LPA spoke on the phone regarding concerns. The purpose of the case management visit was to obtain additional information regarding incident reports submitted to the Department.

Department learned that on 11/15, 11/16, & 11/29/2021 client C1 left the facility unassisted and on 10/29 & 11/7/2021 client C2 also left the facility unassisted. In all occasions clients C1 & C2 were found and came back to the facility. Client C1 physician's report dated 10/20/21 states that client has a diagnosis of intellectual disability; Client C2 has no physician's report on file with admissions agreement to the facility dated 9/16/2019. According with physician's report for client C1, client is not allowed to leave facility unassisted and client C2 facility staff stated that C2 is not allowed to leave facility unassisted. (see copies, LIC 809-D) LPA asked questions and requested more information regarding facility procedures for clients that are not able to leave facility unassisted. Per staff, facility has awake staff 24 hrs/ 7 days a week. In addition, client C1 is known for this behavior and staff is supposed to check on C1 periodically. Both clients bedrooms have sliding doors that open to a deck that leads to outside. There is no gate on the premises once clients open sliding doors.

In addition, LPA learned that client C2 with admissions on 9/16/2019 has no physician's report and/or TB test results on file. Facility staff Sheri Lott stated that facility hasn't been able to acquire a physician's report/medical assessment for client. Title 22 Regulations # 80069(b) states that "In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment."

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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 12/17/2021 01:51 PM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 12/17/2021 at 10:18 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2021
Section Cited
CCR
80078(a)

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80078(a)Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement isn't met as evidenced by: Based on
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Facility agrees to address frequency of elopement drills for staff and review careplan for clients C1 & C2. In addition, to conduct staff training regarding elopment,wandering behaviors & C1 + C2 careplan. Proof of staff training w/participants signature,
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interivew & records review facility staff didn't comply w/this section for 2of2 clients which poses an immediate Health, Safety risk to residents in care.Client C1 elope 3x & C2 2x between 10/29 & 11/29. (see copies)
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trainer signature, what was covered, & date of training to be submitted to CCL by 12/31/21.Facility to submit self certification that clients will be supervised & kept safe by POC date of 12/18/21.
Type B
12/31/2021
Section Cited
CCR80069(b)

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80069(b)In ARFs,prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.This requirement is not met as evidenced by:
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Licensee to ensure that all clients will have complete physician's assement and TB clearance on file as required by Title 22 Regs. Licensee to submit copy of physician's assessment
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Based on file review & interview facility didn't comply w/this section for 1of1 complete medical assessment for client C2 who was admitted on 9/3/19 which poses a potential healthy & safety risk for clients in care.
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LIC 602 for clients C2 to CCL by POC date of 12/31/2021.
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: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


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: WALDO HOUSE
FACILITY NUMBER: 216803577
VISIT DATE: 12/17/2021
NARRATIVE
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Department also learned that administrator Willie Riviore is no longer working at the facility since sometime this year. Facility to submit the following documentation to CCLD - change of administrator by 12/31/2021:

LIC 215 Application Information
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
First Aid Certificate
Administrator Resume (in small facilities if possible)
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan for Residential Care Facilities for the Elderly
LIC 501 Personnel Record
LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed)
TB test that shows "negative" (keep on facility staff file to be reviewed)
LIC 508 Criminal Record Statement
LIC 9182 Criminal Record Exemption Transfer Request
Copy of Personal ID
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)
Detailed employment/Education history with Diploma Certificate

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC809 (FAS) - (06/04)
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