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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803982
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:27:13 PM


Document Has Been Signed on 11/15/2022 12:27 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: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: 8DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Cleda Odiwe (Licensee)TIME COMPLETED:
12:42 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Cleda Odiwe. The inspection is based on Infection Control practices of this facility.
Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility does not perform daily screening of staff and residents just every other day. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE but have not been N95 fit tested. LPA/Licensee discussed visitation and activities. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced October 2022. Smoke Detectors and Carbon Monoxide detector were tested and operational. At approximate 10:00am, LPA/Licensee 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 being associated. Licensee submitted updates of the following documents: LIC 308 Designated Administrator, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan and Liability Insurance.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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Document Has Been Signed on 11/15/2022 12:27 PM - 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: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(1)
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 Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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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 assessed for the amount of $100 per day.
POC Due Date: 11/16/2022
Plan of Correction
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Licensee must remove staff (S1) from the premises until S1 has a clearance as required by law. Licensee will submit a written plan to ensure that regulation was understood along with self-certification that S1 was removed from facility to CCL by POC due date.
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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