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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:44:07 AM

Document Has Been Signed on 08/29/2023 11:44 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:
08/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Sheri Lott, Administrator TIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purposes of conducting a case management, following up on multiple incident reports. LPA arrived at facility jointly with staff Kaylonie Reynolds. There is 5 clients in care and one staff at facility.

The department received 2 incident reports on 8/22/2023, the first occurring on 8/20/23 & the second on 8/21/2023. Incidents state client (C1) sustained injury while performing chores at the facility and refrained from informing staff until following day, as well as C1 eloped on 8/21/2023. Per updated reports received 8/28/2023 C1 has had 2 incidents of removing splint and was transported back to emergency room.

While conducting interviews today with Administrator Sherri Lott & staff, LPA learned on 8/21/2023 C1 tripped on cement steps while wearing bulky shoes and fractured right wrist while attempting to brace self from the fall. The following day (8/22/2023) C1 eloped from facility while staff (S1), walked away for a short period to use the facilities. C1 was not witnessed leaving but was located at Sheriff Substation and returned to facility by S2. When LPA arrived at facility there was only S1 providing care to 5 clients. Facility is being cited today for not providing adequate supervision to clients in care 80078(a).

Civil Penalties are being assessed in the amount of $250 due to a repeat citation issued for the same subsection in less than 12 months. First citation was given on 11/8/2022 & a second was given on 12/16/2022 with Complaint # 21-AS-20221214133305.

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. Exit Interview conducted.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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 08/29/2023 11:44 AM - It Cannot Be Edited


Created By: Shannan Hansen On 08/29/2023 at 10:46 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: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
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 and interview, client C1 eloped facility last week and staff was unable to maintian supervision. C1 was returned to the facility. There was only 1 staff at facility at 8:30am today with 5 clients.
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Per Administrator, additional staff have been hired and have been put on the schedule. C1 has been given othopetic apt for today regarding fractured wrist and will submit results with new staff schedule and plan to determine next steps to ensure the safety of C1.
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This poses an immediate Health and Safety risk to clients in care.

Civil Penalties are being assessed in the amount of $250 due to a repeat citation issued for the same subsection in less than 12 months.
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Administrator will submit that plan to LPA by POC due date, 8/30/2023.

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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: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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