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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 07/24/2024
Date Signed: 07/24/2024 05:05:42 PM


Document Has Been Signed on 07/24/2024 05:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR:CORRINE BIANCOFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 336-1400
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 68DATE:
07/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Executive Director, Corrine Bianco, and Health and Wellness Director, Ashley PerroneTIME COMPLETED:
05:15 PM
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At approximately 3:00PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Corrine Bianco, and Health and Wellness Director, Ashley Perrone. The purpose of today's visit is to follow up on self-reported incident that were submitted to Community Care Licensing (CCL).

Incident Report 1/SOC-341: CCL received an incident report and SOC-341 on 07/19/2024. Reports stated that on 07/06/2024, Staff Member 1 (S1) witnessed Staff Member 2 (S2) place their hand over Resident 1's (R1) mouth with soap suds during a shower due to R1 being agitated. S2 was suspended pending internal investigation and sent notice to the facility of their resignation on 07/16/2024. Facility made all appropriate notifications per regulation. Per report, facility will be conducting elder abuse training the week of 07/22/2024 and 07/29/2024.

LPAs requested documentation. Facility to submit proof of elder abuse training once completed.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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