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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:48:18 PM

Document Has Been Signed on 11/08/2022 12:48 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
SANTA ROSA RO, 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:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff, Devon AnthonyTIME COMPLETED:
01:08 PM
NARRATIVE
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with staff, Devon Anthony. Administrator, Sheri Lott was available by phone and gave permission for staff to sign reports.

LPA is following up on a self-reported incident where client, C1 eloped the facility during the night. Per report, client left the facility and was hiding from staff, resulting in staff being unable to maintain line of sight. Client was eventually brought back to the facility by local law enforcement.

LPA and Administrator discussed options for facility that discourage elopement and changes to the physical plant to assist staff in maintaining line of sight to ensure client safety.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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 11/08/2022 12:48 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 11/08/2022 at 12:31 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: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2022
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Based on record review facility staff did not meet this requirement for 1 of 1 clients which poses an immediate Health and Safety risk to residents in care.
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Administrator will submit a written plan that includes steps that will be taken during an elopement to ensure client safety by POC due date, 11/9/2022.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
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