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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803982
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:18:07 PM

Document Has Been Signed on 11/14/2024 03:18 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:ANTON POINTE, THEFACILITY NUMBER:
216803982
ADMINISTRATOR/
DIRECTOR:		ODIWE, CLEDA M.FACILITY TYPE:
740
ADDRESS:1470 SOUTH NOVATO BLVD.TELEPHONE:
(415) 897-1055
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 10CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Administrator/Licensee, Cleda OdiweTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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11/14/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 residents in care. Facility approved/cleared for 10 non-ambulatory and hospice waiver for 2.

At approximately 1:00pm, LPA and Licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner. Extra food is supplied in a second refrigerator.

Medications were found to be centrally stored. All resident rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens are available to residents in care. Water temperature in sinks accessible to residents in care were measured at 115.1 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 11, 2024. LPA noticed the wall next to the office to be cracked/damaged (Deficiency Cited). Damage is approximately 27 inches in height and 17 inches in width. Licensee states they hit the wall with their scooter by accident and the maintenance guy is suppose to fix it in a few weeks when they return from vacation. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins are stored in the laundry room which is kept locked. Sharps are located in a kitchen drawer and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 3 resident records. All records had the required documentation.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANTON POINTE, THE
FACILITY NUMBER: 216803982
VISIT DATE: 11/14/2024
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LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

See LIC809-D for Deficiency. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC309- Administrative Organization
Liability Insurance
Infection Control Plan (review, update if any changes)
Emergency Disaster Plan (review, update if any changes)

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 03:18 PM - It Cannot Be Edited


Created By: Anthony Loera On 11/14/2024 at 01:34 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: ANTON POINTE, THE
FACILITY NUMBER: 216803982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80087(a)
80087 Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the saftey and well-being of clients, employees and visitors.

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 with one out of one walls being damaged/cracked, approximatley 27 inches in height and 17 inches in width which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee to submit photo proof to CCL of fixed wall when repaired.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Anthony Loera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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