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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803863
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:04:09 PM

Document Has Been Signed on 11/22/2022 12:04 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:TENDER RESIDENTIAL HOMEFACILITY NUMBER:
216803863
ADMINISTRATOR:NDOMO, RODRIGUEFACILITY TYPE:
737
ADDRESS:257 BLACKSTONE DRIVETELEPHONE:
(628) 253-5468
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 3CENSUS: 3DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Back-up Administrator, Kymberlee Franks, and Licensee, Christina YoumbiTIME COMPLETED:
12:15 PM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Visit Inspection and was greeted by Staff. Back-up Administrator, Kymberlee Franks, arrived later during visit at approximately 9:50AM. The inspection is focused on the Infection Control procedures and practices of this facility. Licensee, Christina Youmbi arrived during visit at approximately 11:20AM.

Upon arrival at the facility, LPA had their temperature checked and logged.
LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs at least four times per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Clients. Staff and Clients are screened daily for COVID-19 symptoms.

LPA and Back-Up Administrator discussed the following: Activities, staffing, N95 fit testing, and training. Facility has a plan in place if a staffing shortage were to occur. Facility has submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL).

Fire extinguishers was last serviced October 2022. Smoke and carbon monoxide detectors were not tested to avoid potential behaviors. The last facility fire and evacuation drill was conducted August 2022.

Continued on LIC-809 C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TENDER RESIDENTIAL HOME
FACILITY NUMBER: 216803863
VISIT DATE: 11/22/2022
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Continued from LIC-809

During walk-though, LPA observed 3 spray cans of Lysol located in the two bathrooms for clients, and in the living room. LPA observed Back-Up Administrator immediately place Lysol in a locked cabinet that is inaccessible to Clients and also inform present staff that Lysol needs to be locked away.

LPA and Administrator discussed the importance of having disinfectants, cleaning solutions, and poisons being inaccessible to Clients in Care.

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Affidavit regarding Client/Resident Cash Resources (LIC 400)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Surety Bond
  • Liability Insurance
  • Copy of current and active Administrator Certificate

Documents to be submitted to CCL by due date of Friday, 12/16/2022.

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. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC
9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2022 12:04 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/22/2022 at 11:12 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: TENDER RESIDENTIAL HOME
FACILITY NUMBER: 216803863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)

80087 Buildings and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms 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
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Based on LPA observations, Licensee did not ensure disinfectants and poisons were stored locked and inaccessible to Clients. LPA observed three spray cans of Lysol located in the following areas: 2 in the bathrooms, and 1 in the living room. This poses an immediate health and safety risk to Clients in Care.
POC Due Date: 11/23/2022
Plan of Correction
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LPA observed Administrator lock disinfectants, poisons and sprays during inspection and inform present staff that Lysol was to be kept in a locked cabinet. Licensee to submit a statement that they understand the requirement and will be in future compliance with the regulation by POC due date Wednesday, 11/23/2022, to Community Care Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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