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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803711
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:47:07 PM

Document Has Been Signed on 11/26/2024 12:47 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:SYCAMORE HOMEFACILITY NUMBER:
216803711
ADMINISTRATOR/
DIRECTOR:		HOGAN,WILLIEFACILITY TYPE:
735
ADDRESS:75 JUANITA COURTTELEPHONE:
(415) 761-9790
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 4CENSUS: 4DATE:
11/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Willie Hogan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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At approximately 9:00am, Licensing Program Analyst (LPA) Loera and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Willie Hogan. The purpose of the visit was to follow up self-reported incidents that were submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 10/10/2024 stating on 09/29/2024, Administrator Willie Hogan received a phone called from Staff 1 (S1) indicating the AM medication for Client 1 (C1) were missing. Administrator immediately went to facility and checked the bubble pack to confirm missing medication. Administrator then pulled medication from 10/31/2024 to administer to C1. (Deficiency Cited, LIC809D, regulation 80075(b)).

Incident Report 2: CCL received an incident report on 10/21/2024 stating on 10/16/2024 during the 6AM - 2PM shift Client 2 (C2) missed their medication. Incident report states that on 10/17/2024 when Staff 2 (S2) was passing medication S2 saw medication from 10/16 still in the bubble pack indicating they were not given. Administrator contacted their consultant to do retraining on medication administration. Training was conducted on 10/23/2024. (Deficiency Cited, LIC809D, regulation 80075(b)).

LPAs followed up on a Plan of Correction (POC) that was cited on 10/23/2024. CCL received proof of training paperwork. Review of training showed that documentation was incomplete - not all direct care staff attended the training for 10/29/2024. Facility submitted training for September 2024 which was before the citation was issued. LPAs are requesting for additional training to be submitted.

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.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, Plan of Corrections Letter, and Appeal Rights discussed and provided to Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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Document Has Been Signed on 11/26/2024 12:47 PM - It Cannot Be Edited


Created By: Anthony Loera On 11/26/2024 at 12:25 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: SYCAMORE HOME
FACILITY NUMBER: 216803711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
80075(b)

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80075(b) 80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: Based on interview and document review, Administrator did not ensure that medication
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Administrator agrees to conduct training on medication destruction and administering medication. Proof of training to be submitted to CCL by POC due date, 11/27/2024. Adminsitrator to confirm training will be completed by 12/09/24.
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was administered appropriately to C1 and C2. This is an immediate health and safety risk 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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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