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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803863
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:25:03 PM

Document Has Been Signed on 11/21/2024 12:25 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:TENDER RESIDENTIAL HOMEFACILITY NUMBER:
216803863
ADMINISTRATOR/
DIRECTOR:		NDOMO, RODRIGUEFACILITY TYPE:
737
ADDRESS:257 BLACKSTONE DRIVETELEPHONE:
(628) 253-5468
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 3CENSUS: 3DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH: Staff Member, Gustavo Carvajal, and Administrator, Rodrigue NdomoTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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At approximately 9:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Gustavo Carvajal. Administrator, Rodrigue Ndomo, arrived at approximately 10AM. Facility serves Clients with Disabilities and has an approved fire clearance and capacity for 3 Non-Ambulatory clients. Upon arrival, LPA was informed that there were 3 clients in care and 6 staff members on-site.

At approximately 9:25AM, LPA reviewed the Facility's Staff Roster and found that Staff Member 1 (S1) was not fingerprint cleared or associated to the facility as required. Administrator notified S1 to leave the premises during visit (deficiency cited and civil penalty issued, see LIC809D and LIC421BG, Health and Safety Code 1522(c)(1)).
At approximately 9:45AM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 3 Client bedrooms, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and dangerous items were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Facility's fire extinguishers were last inspected May 2024. Facility's smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted September 2024.

LPA reviewed staff files, client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. P&I monies were documented, secure and not commingled. Administrator's Certificate for Rodrigue Ndomo (7017219735) was current with an expiration date of 10/02/2025.

Continued on LIC809C.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 4
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: TENDER RESIDENTIAL HOME
FACILITY NUMBER: 216803863
VISIT DATE: 11/21/2024
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Continued from LIC809

LPA also followed up on two incident reports that were self-submitted to CCL.

Incident Report 1: CCL received an incident report report on 08/15/2024. Report stated that on 08/10/2024, facility staff prepared Client 1's (C1) medication as they were going out of the community. Facility staff did not prepare two of C1's medications, and therefore C1 missed two medications. Facility made all appropriate notifications per regulation.

Incident Report 2: CCL received an incident report report on 11/13/2024. Report stated that on 11/09/2024, facility staff did not administer a medication to C1. Facility made all appropriate notifications per regulation (deficiency cited, LIC809D, regulation 80075(b)).

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 12/21/2024.

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), LIC421BG (Civil Penalty), Plan of Corrections, Plan of Corrections Letter, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/21/2024 12:25 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/21/2024 at 11:54 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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, resience, or intitial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that Staff Member 1 (S1) had the proper background clearance and/or associations required to provide care at the facility. This poses an immediate health and safety risk to clients in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee sent S1 to be fingerprinted immediately on 11/21/2024. Deficiency cleared during visit.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/21/2024 12:25 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/21/2024 at 11:54 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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above. C1 was not adminstered medications appropriately and missed medications on 08/10/2024 and 11/09/2024. This poses a potential health and safety rights risk to clients in care.
POC Due Date: 12/02/2024
Plan of Correction
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Licensee to submit in-training to review medication administration. Licensee to submit a sign in sheet to CCL that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 12/02/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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