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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803889
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:15:02 PM

Document Has Been Signed on 04/28/2023 01:15 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:FILIA HOME CAREFACILITY NUMBER:
216803889
ADMINISTRATOR:ANGLADE, JUDITHFACILITY TYPE:
735
ADDRESS:1 ARBOR CIRCLETELEPHONE:
(415) 493-6104
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 4DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Judith Anglade, LicenseeTIME COMPLETED:
01:25 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) Shannan Hansen conducted an unannounced Annual Required inspection to this facility and met with Licensee/Administrator Judith Anglade. There are 4 clients, 2 at day programs, 1 with family, and 1 at facility during the time of the visit. There are activities planned for clients during the day if they want to participate.

During facility tour at 9:00 AM on 04/28/2023 with licensee/administrator Judith Anglade, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was fully charged. Carbon monoxide detector and Smoke detectors test was conducted and were operational during this visit. 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 although LPA observed water that had thawed and refroze in kitchen freezer (see LIC812 pics), licensee informed there was a recent power outage. LPA advised Licensee to follow the FDA food safety instructions to keep clients safe (LIC9102 TA). Toxins are stored in a locked closet in kitchen cabinet. Dangerous items were stored inaccessible to clients except paint can and other toxin bottle were observed in backyard (see LIC809-D). There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Medication is centrally stored and secure. Facility hot water temperature in clients' bathroom faucet measured 138.2 &139 degrees F in 2 out of 2 client bathroom faucets, falling out of Title 22 acceptable regulations of 105 to 120 degrees F (see LIC809-D) Licensee adjusted water heater during visit. Disaster drills have been conducted quarterly and last drill was on 3/2/23.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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 8
Document Has Been Signed on 04/28/2023 01:15 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/28/2023 at 12:14 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: FILIA HOME CARE
FACILITY NUMBER: 216803889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and interview with licensee (who stated new hot water heater), did not maintain hot water within regulations on 2 of 2 client's bathroom faucets which poses an immediate health, safety risk to clients in care. Facility hot water ranged between 138.2 F & 139 degrees F in clients' bathrooms while touring facility.
POC Due Date: 05/01/2023
Plan of Correction
1
2
3
4
While touring facility with LPA, Licensee adjusted the temperature on the hot water heater & will ensure hot water falls between the required range of 105 & 120 degrees F. And will send letter to CCL by 5/1/23 they understand the regulation. Facility to keep a seven day log of hot water temperature in client's bathrooms & submit to CCL by the date of 5/5/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 04/28/2023 01:15 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/28/2023 at 12:14 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: FILIA HOME CARE
FACILITY NUMBER: 216803889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in paint and toxic chemical containers were left in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
1
2
3
4
LIcensee will clean up toxic waste on side of house (LIC 812 pics) and send pictures to CCL for proof by 5/2/2023.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Licensee and record review, the licensee did not comply with the section cited above in 2 out of 3 staff did not have current 1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
Licensee will have 2 staff complete American Red Cross certified First Aid training and send copies of certificates for proof by 5/12/2023.
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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
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: FILIA HOME CARE
FACILITY NUMBER: 216803889
VISIT DATE: 04/28/2023
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
At approximately 11:15 AM, LPA reviewed 4 of 4 Client records finding 3 of 4 records missing Medical assessments (LIC9102 TV) and 2 of 3 Staff records also missing medical assessments with TB results (LIC 9102 TV). First aid was not current for 2 staff (see LIC 809D). P & I monies were documented, secure and not commingled. Administrator’s Certificate was current with an expiration date of 6/28/2024 for Judith Anglade.

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 with Licensee and appeal of rights provided..

Department is requesting Licensee to update the following documents and submit to CCL by 5/19/2023:

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

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8