216804010-11-7-2023-21-AS-CFES-CXCV2M-20231107150322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:03:26 PM

Document Has Been Signed on 11/07/2023 03:03 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:	SAHAR MOSALLA		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 243-3959
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 78	DATE:	11/07/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Executive Director, Shawn Mooney		TIME COMPLETED:	12:45 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 10:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director/Administrator, Shawn Mooney. The purpose of today's visit is to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 08/21/2023. Report stated that on 08/18/2023, Resident 1 (R1) informed facility staff that they had a fall and had pain on the right side of their ribs and their hip. Facility staff notified Emergency Personnel and R1 was sent to the hospital to be evaluated. R1 had a diagnosis of a right hip fracture and was scheduled to have surgery. Facility made all appropriate notifications per regulation. Per conversation with Executive Director and Health and Wellness Director, R1 went to rehabilitation after a successful surgery. Their Responsible Party decided to move them back home. At this time, R1 is no longer a resident of the facility. Incident Report 2/SOC-341: CCL received an incident report and SOC-341 report on 09/07/2023 and 09/19/2023. Reports state that on 09/02/2023, Resident 2 (R2) reported to their Responsible Party that they wanted Staff Member 1 (S1) kept away from them. R2 stated to their Responsible Party that S1 grabbed their arm and wanted to have sexual relations with them. Responsible Party reported conversation to facility staff. Facility conducted an internal investigation. During investigation, it was revealed that when R2 was at another facility, there was an individual there that wanted to have sexual relations with R2. R2's Responsible Party and Facility have observed R2 to often be disoriented and confused. Facility conducted an In-Service Training focusing on how to interact with R2 and their symptoms. Facility has re-assigned S1. Facility made all appropriate notifications per regulation. Per conversation with Executive Director, there have been no other occurrences involving R2 and S1. Facility to submit In-Service Training and requested documentation to CCL. Incident Report 3/SOC-341: CCL received an incident report and SOC-341 report on 10/03/2023. Reports state that on 09/30/2023, Resident 3 (R3) and Resident 4 (R4) were observed to be watching a movie together. R4 started to cry and R3 asked them to stop. When R4 did not stop crying, R3 hit R4 in the face. Facility staff separated R3 and R4. Facility made all appropriate notifications per regulation. 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: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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: 11/07/2023

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Continued from LIC809

Incident Report 4/SOC-341: CCL received an incident report and SOC-341 report on 11/02/2023. Reports state that on 10/31/2023, Resident 3 (R3) and Resident 5 (R5) were observed to be sitting on the couch together watching a movie. R3 was observed to hit R5 in the face unprovoked and also grabbed R5's arm tightly. Facility staff separated R3 and R5. Facility made all appropriate notifications per regulation.

Per conversation with Executive Director, R3 had a medication change and has been monitored for any behavioral changes. Facility also notified R3's Physician of the incidents. Facility has also increased staff supervision for R3 by providing a one-on-one caregiver until their medications and behaviors have been stabilized.

No Deficiencies Cited during Visit.

Exit interview conducted. Copy of report and LIC811 (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: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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