216803917-7-8-2022-21-AS-CFGS-CG5QRT-20220708122426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 07/08/2022
Date Signed: 07/08/2022 12:24:45 PM

Document Has Been Signed on 07/08/2022 12:24 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:	SHALAMO HOME		FACILITY NUMBER:	216803917
ADMINISTRATOR:	KIMBO, ANGELINE		FACILITY TYPE:	737
ADDRESS:	200 DARYL AVENUE		TELEPHONE:	(415) 493-6622
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 4		CENSUS: 0	DATE:	07/08/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Priscilla Kimbo - Licensee		TIME COMPLETED:	12:24 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) Carla Fernandes-Goes, LPA Victoria Willis, Licensing Program Manager (LPM) Bethany Moellers, Regional Manager (RM) Carla Nuti-Martinez, Catherine Knight Assistant Deputy Director for Department of Developmental Services (DDS) , Alison Giannini Behavior Specialist II DDS, Pablo Castro Quality Assurance Specialist GGRC, Amanda Pyle GGRC Director, Hayley Garr BCBA (Board Certified Behavior Analyst - Consultant) and Christina Youmbi Consult conducted an office visit and met with Priscilla Kimbo Licensee and Angeline Kimbo Administrator. The purpose of the office meeting was to discuss the recent AWOL of client in care identified at C1 on LIC 811 and issue citations related to violations of Regulation on a Case Management visit and close complaints pending for Shalamo Home # 216803917 and Vilon Home # 496803911. The facility self-reported an incident that occurred on March 17, 2022 when AM shift staff arrived to facility to relieve NOC shift staff, upon their arrival they conducted room checks on the three (3) of four (3) clients in care. One (1) or three (3) clients, C1 was not present in their room. Staff searched the buildings and grounds for C1 and were not able to locate client. Staff contacted Novato Police Department (NPD) to report C1 missing. Per the Special Incident Report (SIR) submitted by licensee, two (2) facility staff went to downtown Novato to search for C1. An individual in the community led staff to C1, who was found in a tent in a homeless encampment. C1 refused to exit the tent. C1 eventually came out of the tent and moved to a busy roadway where they dropped in the middle of the road and would not move. Per the incident report facility staff attempted to verbally redirect C1, staff placed flares in the roadway and redirected traffic as C1 sat in the middle of the intersection. Novato PD arrived on scene and per the Police Report, at approximately 12:30p Officers physically removed C1 from the roadway. Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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: SHALAMO HOME	FACILITY NUMBER: 216803917
	VISIT DATE: 07/08/2022

NARRATIVE

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The Department conducted a case management visit on March 18, 2022 to follow-up on the SIR and learned the following information; on the night of March 16, 2022 C1 refused medications. C1 likes to lock their bedroom door, facility staff have a key and can enter the room if necessary but staff do not perform routine checks on C1. C1 has a history of AWOL behaviors as well as self-injurious behaviors. On March 16, 2022 the NOC (overnight) shift staff consisted of three (3) staff; one (1) lead staff (RBT), one (1) staff trained on behavior (RBT), and one (1) direct care staff (DSP)) – AM staff went to check on client C1 and client wasn't in their bedroom. During the case management visit a citation was issued for responsibility for providing care and supervision 80078 (a) The licensee shall provide care and supervision as necessary to meet the client's needs, due to C1 going AWOL from the facility without the staff’s knowledge (see copies, LIC 809-D). Upon the Departments further review the of documentation on file for client C1 as well as documentation received from Department of Developmental Services (DDS) C1 requires 2:1 staffing 24/7, (Note: facility staffing for the three (3) consumers in care is six (6) staff 24/7, based on documentation for each consumer). At the time of C1s AWOL the facility was not in compliance with required staffing ratio for clients in care. The Department is issuing a Technical Advisory (TA) during today’s meeting and Licensee agrees to immediately implement staffing ratios for clients in care per documentation provided by DDS.

A review of client records provided the following information; according to C1’s Functional Behavior Assessment, Current Individual Behavior Support Plan and Individual Emergency Intervention Plan dated September 2021, line item #5 states; “If ‘client C1’ is engaging in AWOL and there is moving vehicles or other dangers a 2-person escort may be used.” The police report obtained by the Department notes C1 was sitting in the northbound lane on Seventh St with numerous cars actively driving around C1. While in discussion with the police officer C1 was in possession of two lighters, one in each hand and continually lighting them. Due to C1s behavior, statements and refusal to leave the roadway it was determined that C1 was in danger to C1s self, C1 was detained and removed from the roadway. Based on record review the staff failed to implement a 2-person escort or engage C1 in a restraint. Instead staff lite flares which may have caused further risk and directed traffic around C1. A citation will be issued for not following C1’s Emergency Intervention Plan.

Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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: SHALAMO HOME	FACILITY NUMBER: 216803917
	VISIT DATE: 07/08/2022

NARRATIVE

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The Department addressed C1’s Physician Report dated September 29, 2021, which was incomplete (page 2 was blank). The Department issued a citation and requested the facility submit an updated Physician’s Report. On April 1, 2022 the facility submitted an updated Physician’s Report the date on the updated report was dated September 29, 2021. In the “updated report” it indicates on page 2, Section III, Line item 9 under “physician to determine based on the clients capacity for Self-Care if they can leave the facility unassisted”, that client C1 is “able to leave facility unassisted”. Which is in conflict with C1’s staffing pattern of 2:1, 24/7. The Department has requested an update to the POC submitted on April 1, 2022 as well as C1’s Plans to be updated to addressing staffing requirements.

Additionally, the Department met with DDS and learned their expectation of room checks is to be highly individualized based on each person’s needs and it should be included in each person’s IBSP (Individualized Behavior Support Plan). The Department is requesting facility to add information regarding room checks (AM, PM & NOC shifts) to IBSP as recommended by DDS. A technical advisory is being issued today and Licensee agrees to include staff required room checks for each client in care based on determined need.

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: 07/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/08/2022 12:24 PM - It Cannot Be Edited

Created By: Carla Fernandes-Goes On 06/15/2022 at 03:31 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: 07/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/22/2022 Section Cited CCR 80068.2	1 2 3 4 5 6 7	80068.2 Needs and Services Plan. This requirement is not met as evidenced by:Based on observation, interview, record review, licensee did not comply with the section cited above in 1 out of 1 Behavioral & Services	1 2 3 4 5 6 7	Licensee agrees to ensure that all Behavioral & Services Plan are followed, and that staff will receive the proper training to learn and understand how to work with each clients' needs. Licensee to submit proof of staff
	8 9 10 11 12 13 14	Plan for C1 on file which poses/posed a potential health, safety or personal rights risk to persons in care. Department learned that C1’s Functional Behavior Ass, Current Behavior Support Plan & Individual Emergency Plan dated 9/21, line item #5 states; “If ‘client C1’ is engaging in AWOL and there is moving vehicles or other dangers a 2-person escort may be used.” Police report obtained notes C1 was sitting in the northbound lane on Seventh St w/ numerous cars actively driving around C1.	8 9 10 11 12 13 14	training w/ date, time, topics, & participants signature in addtion to a plan on how administrator and staff will ensure that proper measures are taken to follow these plans by POC due date of xxxx.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 07/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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