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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803711
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:01:02 PM

Document Has Been Signed on 01/09/2025 03:01 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: 3DATE:
01/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Willie Hogan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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At approximately 1:30pm, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Willie Hogan. The purpose of the visit was to follow up on a self-reported incidents that were submitted to Community Care Licensing (CCL) on 12/18/2024 and 01/08/2025.

Incident Report 1: Incident report 1 states on 12/15/2024 during the 8am medication time Client 1 (C1) missed their medications. Around 4pm on 12/15/2024, House Manager went through the medications and found that C1’s 8am medications were not given and reported it to the administrator. The medications were then discarded.

Incident Report 2: Incident report 2 states on 01/05/2025 around 7:00pm during the pm shift, Staff 1 (S1) went to give C1 their medication when they noticed there was medication not given during the am shift as it was still in the bubble pack. S1 then reported the incident to the administrator who immediately went to the facility to check and then discarded the medication.

Per conversation with Administrator, QA (Quality Assurance) will be conducting retraining on medication on 02/13/2025.

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), and Appeal Rights discussed and provided to Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 01/09/2025 03:01 PM - It Cannot Be Edited


Created By: Anthony Loera On 01/09/2025 at 02:17 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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
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 administering medication. Proof of training to be submitted to CCL by POC due date, 01/10/2025. Administrator to confirm training will be completed by 02/14/2025.

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was administered appropriately to C1 on 12/15/2024 and 01/05/2025. 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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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