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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:58:53 PM

Document Has Been Signed on 05/22/2024 01:58 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/
DIRECTOR:		LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 5CENSUS: DATE:
05/22/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:CEO Matt Omelagah, Regional Manager Paula SiffletTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM) Victoria Bertozzi, LPM Bethany Moellers, Licensing Program Analyst (LPA) Dina Alviso, LPA Helena Rummonds, and Omelagah representatives including CEO Matt Omelagah and Regional Manager Paula Sifflet.

The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to the Licensee which is based on recent concerns identified by the Licensing Agency regarding the operation of this facility including but not limited to: complaint investigations that have been substantiated regarding insufficient staffing and medication administration:

Items addressed in today's meeting include but are not limited to patterns and trends in the areas below:

· Insufficient staffing: an incident occurred at the facility where a client (C1) who is required to be left in line of sight due to their excessive behaviors. C1 was left out of line of sight and was able to ingest foreign objects. The objects included: batteries, a pushpin, and a nail. Staff at the facility at the time were unaware that C1 ingested the objects until C1 informed the Administrator.
· Another incident occurred where a visitor arrived at the facility to drop off a client and was asked by staff to stay at the facility to help supervise the clients in care because the other staff left while on shift.

· PRN medications not being administered as prescribed: multiple clients had medication(s) that were intended to be used as needed for agitation. Clients have received the medication when observed to not be sleeping after 10PM, and repeatedly exiting their rooms with requests.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WALDO HOUSE
FACILITY NUMBER: 216803577
VISIT DATE: 05/22/2024
NARRATIVE
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Continued from LIC809

A potential civil penalty is under review and may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 01:58 PM - It Cannot Be Edited


Created By: Helena Rummonds On 05/22/2024 at 11:44 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: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2024
Section Cited
CCR
80064(a)(2)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications:
(2) Knowledge of the requirements for providing the type of care and supervision needed by clients... This requirement was not met as evidenced by:
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Licensee to submit a plan indicating how they are going to ensure sufficient staffing. Per conversation with Licensee, staffing has been increased and has a staffing plan moving forward has been implemeted.
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Administrator not ensuring that facility had adequate staffing to provide the proper care and supervision to clients in care.
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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