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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:59:23 PM


Document Has Been Signed on 01/05/2024 02:59 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, THEFACILITY NUMBER:
216804010
ADMINISTRATOR:SHAWN MOONEYFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 243-3959
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 83DATE:
01/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Health and Wellness Director, Mildred SantosTIME COMPLETED:
01:30 PM
NARRATIVE
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At approximiately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies Visit and met with Health and Wellness Director, Mildred Santos. Corporate Director of Operations, Scott Bissey, was available by telephone.

During the course of the Complaint Investigation dated for 01/04/2024, LPA conducted interviews. LPA learned that a resident went to the hospital with another resident's confidential medical paperwork. This incident was not reported to Community Care Licensing (CCL) and was not documented on an LIC 624/Unusual Incident Report Form (This deficiency has been cited, see LIC809D, Regulation 87211).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Plan of Corrections reviewed and developed with Health and Wellness Director and Corporate Director of Operations. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
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 01/05/2024 02:59 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: VINCENT, THE
FACILITY NUMBER: 216804010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...
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Licensee to provide training to all care staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 01/15/2024.
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This requirement is not met as evidenced by:
Based on interviews conducted, the Licensee did not comply with the section cited above and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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