<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803982
Report Date: 10/19/2022
Date Signed: 10/19/2022 11:53:10 AM


Document Has Been Signed on 10/19/2022 11:53 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:ANTON POINTE, THEFACILITY NUMBER:
216803982
ADMINISTRATOR:ODIWE, CLEDA M.FACILITY TYPE:
740
ADDRESS:1470 SOUTH NOVATO BLVD.TELEPHONE:
(415) 897-1055
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:10CENSUS: 7DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Philomene Desire (staff)TIME COMPLETED:
12:07 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) Cuadra arrived unannounced to conduct a Case Management visit regarding an AWOL that occurred on 09/20/2022 and was greeted by staff Philomene Desire, Cleda Odiwe (Licensee) was available by phone and gave authorization for staff to sign the report.

On 9/22/22 CCL received a self-incident report reporting resident's (R1) AWOL. Per incident report, on 9/20/22 R1 suddenly left the facility around 1pm. Licensee and staff followed R1 and asked them to return to the facility, but R1 refused then Licensee contacted a family member by phone and resident refused again to talk to them. Licensee contacted LPA Fernandes-Goes who advise them to contact the Police. At approximate 2:20pm, R1 got a taxicab from the North Bay Cooperative Service to return to their home. Per R1's responsible party, R1 was reported safe at their house. During today's visit LPA obtained pertinent documents and conducted confidential interviews with staff. Per Physician's report dated 8/10/2022, R1 is able to leave the facility unassisted. Facility staff followed all the proper procedures, they also remained with resident at all times until they got the taxi and contacted responsible parties including CCL to notify them about the incident.

At approximate 10:30am, LPA/staff observed staff (S1) was providing care to residents at the facility and was not associated to the facility. LPA informed Licensee that S1 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance. Also, during walk through the facility, LPA/staff observed two out of two fire extinguishers were not charged and serviced since June 2021.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.***Civil Penalty is being assessed for the amount of $100 per day for Criminal record clearance. Exit interview was conducted with Licensee via phone and a copy of report was given to staff.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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 2


Document Has Been Signed on 10/19/2022 11:53 AM - It Cannot Be Edited

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: ANTON POINTE, THE
FACILITY NUMBER: 216803982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e)All individuals... shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Dpt... This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on LPA observation, record review and interview with Licensee did not ensure to obtain a criminal record clearance for staff (S1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assesed for the amount of $100 per day.
8
9
10
11
12
13
14
Type A
10/20/2022
Section Cited

1
2
3
4
5
6
7
87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fire extinguisher was charged but not serviced which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2