216804010-7-21-2023-21-AS-CFES-CTXTPW-20230721145500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:55:05 PM

Document Has Been Signed on 07/21/2023 02:55 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:	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: 71	DATE:	07/21/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Corporate Director of Operations, Scott Bissey		TIME COMPLETED:	03:05 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	At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit, and met with Corporate Director of Operations (CDO), Scott Bissey. The purpose of the visit was to follow up on self-reported incidents that was submitted to Community Care Licensing (CCL), and to follow up on Facility Administrator paperwork. Incident Report 1/SOC341: CCL received an incident report on 07/11/2023. Report stated that on 07/06/2023, Staff Member 1 (S1) reported to Management that they observed Staff Member 2 (S2) slapping Resident 1 (R1's) face while providing care. S1 stated that the incident was observed approximately 3 weeks prior and did not report the incident to Management until 07/06/2023. Incident Report 2/SOC341: CCL received an incident report on 07/13/2023. Report stated that on 07/10/2023, Facility conducted an internal investigation which revealed that S1 observed S2 striking Resident 2 (R2's) hands while they were waving them in the air. Report stated that the incident was observed by S1 approximately 3 months prior and did not report the incident to Management until 07/10/2023. LPA conducted interviews and obtained facility documents. Per conversation with CDO, Facility suspended S2 from the Facility while an internal investigation was completed. Facility's internal investigation resulted in the Facility terminating S2. An In-service Training for all staff on the topics of Mandated Reporting, Elder Abuse, and Documentation will be conducted and has been scheduled. Facility to submit proof of In-service Training to CCL by 07/31/2023. LPA also followed up with the CDO regarding Administrator paperwork to be submitted to CCL. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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: 07/21/2023

NARRATIVE

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Continued from LIC809

Per CDO, an Executive Director will be hired for the facility soon and Administrator documents will be submitted for Interim Executive Director, Sahar Mosalla, by Tuesday, 07/25/2023. Until an individual is hired, CDO and Interim Executive Director will be overseeing the facility. CDO understands that a new Administrator packet will need to be submitted to CCL when an Executive Director is hired. LPA reviewed Administrator Documents to be submitted:

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)

LPA conducted a walk through with CDO.

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: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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