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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 05/05/2023
Date Signed: 05/05/2023 10:34:56 AM

Document Has Been Signed on 05/05/2023 10:34 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:
05/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Devon Seaver-Brosh (Lead Staff)TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) arrived unannounced to the facility for the purpose of conducting a case management visit to follow up on areas of concerns regarding building and grounds issues found by another agency during a recent visit conducted on 4/18/23. During today's visit LPA met with lead staff Devon Seaver-Brosh.

Per agency report, the facility has several items that are out of compliance. During today's visit LPA found the following items are still needing to be repaired:
  • Front door window panes are broken since 4/16/23. Per lead staff, glass vendor has performed an assessment on 4/28/23 to take measurements of window panes. However, as of today, the facility is not able to provide an update of date scheduled for them to come and replace the window.
  • The facility bathrooms still needs to be repaired including parts of flooring that are loose and caulking.
  • The facility refrigerator light is still not working, and shelving bins on door had not been repaired/replaced.


LPA/lead staff observed walkway was clear of glass and free from obstructions. Per lead staff, toaster oven located on the kitchen that needed to be cleaned has been discarded and drawer in the living room cabinet had been fixed as well as washing machine that was not draining properly. The facility oven had recently been repaired, but still has some temperature regulation issues, but they have a pressure cooker and air fryer. The facility has placed work orders to landlord for items above listed and they are in the process of getting them fixed, but they are unable to provide a specific date of when those will get fixed. Medication and medication records have been reviewed. Facility Administrator agreed to submit updates and time frame of items that need to be repaired/replaced.

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 lead staff and appeal of rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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Document Has Been Signed on 05/05/2023 10:34 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/05/2023 at 09:49 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: SHALAMO HOME
FACILITY NUMBER: 216803917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2023
Section Cited
CCR
80087(a)

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80087 Buildings and ground (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 requierment was not met as evidenced by:
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The Administrator agreed to submit dates that items that need to be fixed have been scheduled to be repaired/replaced to CCL by POC due date. Then Administrator will submit on or before 5/19/23 pictures of items repaired as proof of services were done.
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Based on records review, observations and interviews with facility staff, the facility did not ensure to maintain the building in good repair in a timely manner which poses an immediate risk to the health and safety of clients in care.
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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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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