<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803711
Report Date: 08/08/2023
Date Signed: 08/08/2023 12:58:15 PM

Document Has Been Signed on 08/08/2023 12:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
216803711
ADMINISTRATOR:MARTIN, GAMALIEL DAN G.FACILITY TYPE:
735
ADDRESS:75 JUANITA COURTTELEPHONE:
(415) 761-9790
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 4CENSUS: 3DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Willie Hogan, House ManagerTIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by staff Editha Bulalacao, house manager, Willie Hogan was notified and arrived shortly after, Administrator was unavailable at time of visit. One client was leaving for day program and one is at rehab facility at the time of the visit. There are 3 clients in the facility.

LPA toured the facility on 8/8/2023 at 8:30 AM with house manager Willie Hogan, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/21/2023 at the time of the visit. Facility smoke detectors were found to be functioning properly at the time of the visit, facility did not have a carbon monoxide detector at 9:05 AM (see LIC809D). Hot water temperature measured between 114.8 degrees F and 121 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 2 client’s bathrooms while touring facility on 8/8/2023 at 8:50 AM (see LIC809D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility garage. Dangerous/sharp items were stored in kitchen cabinet that was observed unlocked at time of visit on 8/8/2023 at 8:40am (see LIC 809D) accessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads as required by Title 22 Regulations # 85088(c)(4) on 8/8/2023.

(Continue LIC 809-C)

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 08/08/2023 12:58 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/08/2023 at 11:52 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: SYCAMORE HOME
FACILITY NUMBER: 216803711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, facilty did not have any carbon monoxide detectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
1
2
3
4
Facility obtained required carbon monoxide detector (2) during inspection. POC has been cleared during visit.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 2 client bathroom faucets exceeded regulations of 120 degrees F, testing at 121 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
1
2
3
4
Facility to ensure hot water temperature is maintainted within regulation - 105 to 120 F. Facility to submit a LIC 9098 self certification that hot water has been adjusted to be within regulation by POC date 8/9/2023 & begin monitoring for the next 7 days. Administrator to submit a 7 day log taken from the residnet's bathrooms to CCL by 8/17/2023. ***Faility adjusted hot water during the visit.
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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SYCAMORE HOME
FACILITY NUMBER: 216803711
VISIT DATE: 08/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review of three clients and a sample review of five staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 10:00 AM on 8/8/2023 and learned that 3 of 3 clients have an updated reappraisal/needs & care plan and physician’s report. P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not commingle, and ledgers are current on 8/8/2023.

Medications were observed by LPA centrally stored in an unlocked cabinet in the kitchen on 8/8/2023 at 8:40 AM (see LIC809D). LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 8/8/2023 at 12:00 PM. Centrally Stored Medication Records (CSMR) on 8/8/2023 at 12:20 PM were currently for 2 out of 2 clients in the facility.

LPA conducted a sample review of staff records on 8/8/2023 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of CPR & 1st Aid certification for staff records that were reviewed. Gamaliel Martin Administrator Certificate # 6036010735 expired on 6/12/2023 and renewal is pending.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted every six months but need to be quarterly (see LIC 9102 TV) with the last one being conducted on 6/7/2023.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

(Continue LIC 809-C)

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/08/2023 12:58 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/08/2023 at 12:00 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: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, The licensee did not comply with the section cited above and Medication cabinet was unlocked/ unsecured in kitchen within reach of clients. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
1
2
3
4
Staff immediately secured the medication. POC cleared at time of visit.
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds - (g) Disinfectants, cleaning solutions, poisons, ... and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the Administrator did not ensure the regulation above do to sharps/ knives and other items that could pose a danger were observed unlocked and accessible to clients. This is an immediate health & safety risk to clients in care.
POC Due Date: 08/09/2023
Plan of Correction
1
2
3
4
House manager was asked to lock the items during the visit. Administrator will train all staff on regulation 80087(g) and submit a copy with date, time, duration, subject, attendees and their signatures to Community Care Licensing (CCL) to clear the citation by POC due date 08/9/2023
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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SYCAMORE HOME
FACILITY NUMBER: 216803711
VISIT DATE: 08/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA is requesting the following documents be updated and submitted to CCL by 8/22/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6