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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 03/18/2022
Date Signed: 03/19/2022 10:06:08 AM

Document Has Been Signed on 03/19/2022 10:06 AM - 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:SHALAMO HOMEFACILITY NUMBER:
216803917
ADMINISTRATOR:KIMBO, ANGELINEFACILITY TYPE:
737
ADDRESS:200 DARYL AVENUETELEPHONE:
(415) 493-6622
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 3DATE:
03/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angeline Kimbo - AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with staff Devon Seaverbrosh. The purpose of the case management visit was to obtain additional information regarding incident report due to elopement of client C1 that occurred on March 17, 2022 - facility reported to the Department on the same day.

LPA interviewed Angeline Kimbo administrator on March 17, 2022. Per administrator, AM shift had just got to the facility - facility staff were switching shifts - went to check on client C1 and client wasn't in the bedroom. Facility staff looked around the house and didn't find C1. When 2 care staff went to downtown Novato, they found client C1 at encampment on a tent with a guy possibly doing drugs. Client C1 ran out of the tent into the street - police was on site. Client C1 has returned since the episode. Client C1 was asleep during this visit, C2 was with another staff in the living room/kitchen, and C3 was asleep. Client C1’s physical assessment dated September 29, 2021 is incomplete – page 2 has no information noted by doctor regarding client. (see LIC 809-D) However, Behavior Assessment and Support Plan dated September 2021 states “Target Behavior #2 AWOL”. Furthermore, on March 16, 2022 facility had 3 staff on NOC shift - 1 lead staff (RBT), 1 staff trained on behavior (RBT), and 1 direct care staff (DSP).

LPA arrived at the facility and was welcome by staff. There were 5 staff and 4 of them were not wearing a mask. Staff S1 stated that she was drinking – believed to be a cold drink. LPA asked the other staff why they were not wearing a mask. Staff didn’t answer and placed their masks on. (see LIC 809-D)

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 3
Document Has Been Signed on 03/19/2022 10:06 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 03/18/2022 at 04:03 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: SHALAMO HOME
FACILITY NUMBER: 216803917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2022
Section Cited
CCR
80078(a)

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80078(a)Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement isn't met as evidenced by: Based on
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Facility agrees to conduct staff training regarding elopment, wandering behaviors & C1 careplan and plan activities. Proof of staff training w/participants signature, trainer signature, what was
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interivew & records review facility staff didn't comply w/this section for 1of1 client which poses an immediate Health, Safety risk to residents in care.Client C1 eloped & was found at neighbors homeless encampment.(copies)
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covered, & date of training to be submitted to CCL by 4/1/2022. Facility to submit self certification that clients will be supervised & kept safe by POC date 3/19/2022..
Type B
04/01/2022
Section Cited
CCR80069(e)

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Medical Assessment:The licensing agency shall have the authority to require the licensee to obtain a current written medical assessment. This requirement is not met as evidenced by: Based on
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Licensee to ensure that all clients before moving into the facility will provide licensee with a complete physician report that must be available for the Department to review in a timely matter.
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interivew & records review licensee didn't comply w/this section for 1of1 client which poses an immediate Health, Safety risk to residents in care.Client C1 has an incomplete medical assessment on file (see copy)
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 Facility to provide Department with a copy of complete physician report for client C1 by POC date of 4/01/2022.
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:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/19/2022 10:06 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 03/18/2022 at 04:19 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: SHALAMO HOME
FACILITY NUMBER: 216803917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
80072(a)(2)

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Personal Rights:To be accorded dignity in his/her personal relationships with staff and other persons.This requirement isn't met as evidenced by: Based on observation facility staff didn't comply w/ this section for
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Facility to ensure that all staff are wearing masks at all times no matter the vaccination status as required by the Department. Facility to submit a self certification for each staff at facility signed
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3 of 3 clients which poses an immediate Health, Safety risk to residents in care. LPA arrived at facility unannonced and observed 4 out of 5 staff without a mask inside the facility.
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and dated that each staff understands that they are required to use masks all the time to CCL by POC date of 4/1/2022.

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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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
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