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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803917
Report Date: 02/14/2022
Date Signed: 02/16/2022 10:02:29 AM

Document Has Been Signed on 02/16/2022 10:02 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:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jasmin Gongora - staffTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Jasmin Gongora. All clients were present at the facility. At this time none of the clients at this facility are going into day programs. There are activities planned for clients during the day if they want to participate.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 2/14/2022 with staff Jasmin facility was found 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 found to be last charged on 03/2021 at the time of the visit. Carbon monoxide detector was operational during visit. 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. Toxins are stored in a locked cabinet inside the garage. Dangerous items were stored inaccessible to clients. 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. Facility hot water temperature in clients' bathroom faucets measured between 118.9 degrees F and 118.4 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted monthly with the last one being conducted on 2/1/2022.

In addition, LPA during visit learned that clients C1 have no physician's report and/or TB test result and C2 has no TB test result on file for the Department to review. At this time 2 out of 3 clients don't have all the medical requirements according with Title 22 Regulations. (see confidential name list, copy, LIC 809-D)

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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: 02/14/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility, table with hand sanitizer and other items designated for visitors are at entrance. Staff before coming into work has temperature checked. Facility has PPE supply stored in garage cabinet. There has been new staff hired and new clients since COVID-19. Clients’ medications are stored and locked in medication cabinet inside office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available zoom and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and facility still working towards N-95 fit testing.


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.

Department is requesting Licensee to update the following documents and submit to CCL by 2/21/2022:

LIC 308 Designated
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/Resident’s
Copy of lease for facility
Copy of Current Administrator's Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2022 10:02 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 02/14/2022 at 02:45 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: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
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. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 3 client's physician report on file which poses/posed a potential health, safety or personal rights risk to persons in care. LPA review files for clients and learned that client C1 has no physician's report on file.
POC Due Date: 02/28/2022
Plan of Correction
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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. Facility to provide Department with a copy of complete physician report for client C1 by POC date of 2/28/2022.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 clients files which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed client's files and learned that client C1 and C2 don't have a record of TB test results on file at the facility.
POC Due Date: 02/28/2022
Plan of Correction
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Licensee to ensure that before client moves into the facility, facility will have will have a complete physician report and TB test clearance available for clients and available for the Department to review when needed. Facility to acquire TB test clearance for C1 and C2. Copy of TB test clearance to be submitted to CCLD by POC date of 2/28/2022.
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: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


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