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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 08/04/2022
Date Signed: 08/05/2022 08:18:21 AM

Document Has Been Signed on 08/05/2022 08:18 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:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR:LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 5CENSUS: 5DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Leonje Silas Williams - staffTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned that there are related deficiencies observed during the visit. LPA met with Leonjae Sillas Williams - staff. Following item were observed during investigation visit:

Department has learned that during elopement client C1 was found by sheriff not wearing shoes. In addition, during LPA visit to facility on 6/6/2022, LPA observed that C1 had no shoes on while standing alone in the kitchen and nails were long with some broken pieces (see pic). Facility staff stated that he doesn’t like to wear shoes. However, C1’s nails were length might be a barrier for him to wear shoes. Client C1 did not have shoes during visit and was observed with long unkept toenails. Physician’s Report dated 12/27/2021 states that client C1 is “not able to care for all personal needs”. (see picture, confidential name list, LIC 809-D)

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: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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 08/05/2022 08:18 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 08/01/2022 at 03:12 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: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2022
Section Cited
CCR
80072(a)(2)

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80072(a)(2) Personal Rights, This requirement isn't met as evidenced by: Based on obs, interviews, records reviewed facility didn't comply w/section cited above 1outof1 client which poses a potential healthsafety or
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Facility to ensure that clients are to be accorded safe, healthful & comfortable accommodations to meet his/her needs. Facility to submit CCLD w/a self-certification that licensee staff, and administrator
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personal rights risk to clients in care. During LPA visit to facility on 6/6/22 C1 didn't have shoes during visit and was observed with long unkept toenails.In addition, C1 was found by sheriff not wearing shoes.
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understand and will keep clients care needs met at all times by POC due date of 08/18/2022.

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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: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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