216804010-6-22-2023-21-AS-CFES-CT2PCN-20230622111213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:12:18 AM

Document Has Been Signed on 06/22/2023 11:12 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:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	MELON RIVERA		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 243-3959
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 77	DATE:	06/22/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Interim Executive Director, Sahar		TIME COMPLETED:	11:20 AM

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	At approximately 9:20AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Case Management - Other Visit and met with Interim Executive Director, Sahar Mosalla. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL), and to request for Administrator paperwork. LPA reviewed the following report with Interim Executive Director: Incident Report 1: CCL received an incident report on 06/13/2023. The report states that on 06/12/2023, Resident 1 (R1) hit their arm against the bench during their shower which resulted in a skin tear with no other signs of injury. On 06/13/2023, staff observed R1 to be in pain. Facility contacted Emergency Personnel and R1 was transported to the hospital where it was determined they had an arm fracture. R1 was scheduled to see a surgeon. Facility made all appropriate notifications per regulation. LPA discussed R1 with Interim Executive Director. As of today, 06/22/2023, R1 has been observed to be at baseline and is doing well. Facility has continued to communicate with R1, their Responsible Party, and their Physician regarding R1's care needs. LPA also discussed the recent change in management for the facility. At this time, the facility will be overseen by Corporate Executives, Sahar Mosalla and Scott Bissey. Per conversation with Interim Executive Director, Facility has ensured that all staff know who to contact in the event of an emergency or resident incident. LPA was also informed that a resident meeting has been scheduled to address any questions they may have. Continued on LIC809

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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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: VINCENT, THE	FACILITY NUMBER: 216804010
	VISIT DATE: 06/22/2023

NARRATIVE

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Continued from LIC809

LPA is requesting the following Administrator paperwork:

Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Documents to be submitted to CCL by due date of Monday, 07/03/2023.

LPA conducted a walk through Interim Executive Director.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC 811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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