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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 02/08/2024
Date Signed: 02/08/2024 12:39:30 PM


Document Has Been Signed on 02/08/2024 12:39 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: 72DATE:
02/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH: Regional Health and Wellness Director Roschelle Factor, Regional Operations Specialist, Sahar MosallaTIME COMPLETED:
12:50 PM
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At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Regional Health and Wellness Director, Roschelle Factor, and Regional Operations Specialist, Sahar Mosalla. 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 01/29/2024. Report stated that on 01/21/2024, three medications were found in a medication cup in Resident 1's (R1) bedroom. Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation.

Incident Report 2: CCL received an incident report on 02/02/2024. Report stated that on 01/23/2024, Resident 2 (R2) was given an extra dose of medication at the request of R2's Responsible Party. Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation.

Incident Report 3: CCL received an incident report on 02/02/2024. Report stated that on 01/27/2024, Resident 3 (R3) was given an extra dose of medication. Report stated that R3 was given half a tablet of medication by Staff Member 1 (S1), and then was given one full tablet of medication by Staff Member 2 (S2). Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation.

LPA also requested for updated Administrator Paperwork. During visit, LPA was informed that Facility has a new Executive Director, Sam Faye. LPA requested for the following documents to be submitted to the Regional Office so they can be processed as the new Administrator.

Administrator Documents to be submitted to CCL by 02/18/2024.

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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 02/08/2024 12:39 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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care
(c)If resident...unable to determine... need for nonprescription PRN medication... facility...shall assist..with self-administration...(2)Once ordered by the physician the medication is given according to the physician's directions. This requirement was
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Licensee conducted In-Service Training on Medication Management and Narcotics and Controlled substances for all medication technicians on 01/25/2024. Deficiency cleared during visit.
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not met as evidenced by: Based on document review, Licensee did not comply with the section cited above. R1, R2, and R3 were not given medications as prescribed and R3 was also given PRN medication. This poses an immediate health, safety or personal rights 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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 02/08/2024
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Continued from LIC809

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)

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



Facility conducted a in-service training covering Medication Management and Narcotics and Controlled Substances on 01/25/2024. LPA was provided with a copy of training documentation and cleared the deficiency cited today, 02/08/2024 during visit.

Exit interview conducted. Plan of Corrections reviewed and developed with Regional Health and Wellness Director and Regional Operations Specialist. Copy of report, LIC9099D, Plan of Corrections, and Appeal Rights discussed and provided to Regional Health and Wellness Director and Regional Operations Specialist. 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: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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