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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803889
Report Date:
04/29/2024
Date Signed:
04/29/2024 01:48:54 PM
Document Has Been Signed on
04/29/2024 01:48 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:
FILIA HOME CARE
FACILITY NUMBER:
216803889
ADMINISTRATOR/
DIRECTOR:
ANGLADE, JUDITH
FACILITY TYPE:
735
ADDRESS:
1 ARBOR CIRCLE
TELEPHONE:
(415) 493-6104
CITY:
NOVATO
STATE:
CA
ZIP CODE:
94947
CAPACITY:
6
CENSUS:
4
DATE:
04/29/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Administrator Manilia Boujour
TIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and was greeted by Administrator Manilia Baujour. LPAs and Administrator discussed the purpose of the visit.
LPAs and Administrator initiated a tour of the facility around 09:45 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. LPAs observed restroom to be equipped with two sinks. Faucet lever for hot water was not functional on one of the sinks. Water temperature in sinks accessible to clients measured at 70 and 125 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation.
Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the hallway closet. Personal Protective Equipment is stored in the garage.
Fire extinguishers were last serviced May 21, 2023. Facility has smoke and carbon monoxide detectors located throughout the facility that were tested and operational during inspection. Most recent fire/disaster drill was conducted 03/02/2024. Client cash resources could not be reviewed during inspection.
Four staff files and four client files were reviewed. 3 of 4 staff have required First Aid and CPR certificates. Remaining required documents could not be located by LPAs and Administrator. 4 of 4 clients did not have Medical Assessments or TB on file. 4 of 4 clients did not have updated Needs and Services Plans on file.
Continued on LIC809C
SUPERVISORS NAME
:
Victoria Bertozzi
LICENSING EVALUATOR NAME
:
Helena Rummonds
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/29/2024
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
6
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:
FILIA HOME CARE
FACILITY NUMBER:
216803889
VISIT DATE:
04/29/2024
NARRATIVE
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Continued from LIC809
Medications and medication records were reviewed. Facility does not keep a Centrally Stored Medication and Destruction Record (CSMDR). Facility keeps a Medication Administration Record (MAR). LPAs provided Administrator with a CSMDR to begin keeping on file for all clients. Administrator Certificate for Administrator, Manilia Baujour (6061449735) expired on 12/3/2023 and is on the departments pending list for renewal.
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, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on forms confirms receipt of documents.
LPA is requesting the following documents to be submitted to Community Care Licensing by 05/29/2024:
LIC 500 Personnel Report
LIC 9020 Resident Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME
:
Victoria Bertozzi
LICENSING EVALUATOR NAME
:
Helena Rummonds
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/29/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6
Document Has Been Signed on
04/29/2024 01:48 PM
- It Cannot Be Edited
Created By:
Helena Rummonds
On
04/29/2024
at
12:47 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:
04/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having an unstable wooden step leading to the backyard patio which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/27/2024
Plan of Correction
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2
3
4
Administrator agrees to repair unstable wooden step leading to the backyard and submit photos of the repairs to the LPA by POC due date of 5/27/2024.
Type B
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
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4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 sinks, one of which was too high and the other was inoperable which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/27/2024
Plan of Correction
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Administrator agrees to adjust the temperature on the water heater and to repair the faucet handle so the sink can deliver warm water. Administrator agrees to submit hot water temperature log in both sinks accessible to clients for the week of May 12-18. Temperature log and proof of repairs to be submitted to LPA by POC due date of 05/27/2024.
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:
Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE:
04/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/29/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
04/29/2024 01:48 PM
- It Cannot Be Edited
Created By:
Helena Rummonds
On
04/29/2024
at
12:47 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:
04/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having health screenings for 4 of 4 staff which poses a potential health risk to persons in care.
POC Due Date:
05/27/2024
Plan of Correction
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4
Administrator agrees to get updated health screenings for all staff and submit to LPA by POC due date of 5/27/2024.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not having Needs and Services Plans in 4 out of 4 clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/27/2024
Plan of Correction
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Administrator agrees to provide updated care plans for all clients and submit to LPA by POC due date of 5/20/2024.
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:
Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE:
04/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/29/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
04/29/2024 01:48 PM
- It Cannot Be Edited
Created By:
Helena Rummonds
On
04/29/2024
at
12:47 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:
04/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having medical assessments for 4 of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/27/2024
Plan of Correction
1
2
3
4
Administrator agrees to provide updated Medical Assessments for all clients and submit to LPA by POC due date of 5/27/2024.
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:
Victoria Bertozzi
LICENSING EVALUATOR NAME:
Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE:
04/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/29/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6