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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804130
Report Date: 10/17/2023
Date Signed: 10/17/2023 11:39:48 AM

Document Has Been Signed on 10/17/2023 11:39 AM - 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:AVERY LANEFACILITY NUMBER:
216804130
ADMINISTRATOR:HILDEBRAND, CAMILLEFACILITY TYPE:
772
ADDRESS:200 ATHERTON AVETELEPHONE:
(415) 686-6127
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
10/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Anna-Lena Karlsson, Program DirectorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to continue a complaint investigation. During today's investigation, while reviewing medication records with Program Director Anna-Lena Karlsson, it was revealed 3 clients (C1,C2, &C3) were not given some of their medications on 10/16/2023. C1 & C3 missed their noon medication and C2 missed one of their morning medications. No adverse side effects noticed. Program Director did not know why this was missed.

Facility uses KIPU electronic Medication Record Keeping system that indicates if a client took their medication or not & why, as well as what time, and which staff documented it. System also shows clients signature indicating knowledge of. LPA reviewed the facility's "Medication Protocol" with Program Director. Additional safeguards and precautions will be put in place. Staff will attended refresher training on medication procedures with facility Nurse.

LPA is citing the facility for failure to assist a client with self-administration of prescription medications.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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Document Has Been Signed on 10/17/2023 11:39 AM - It Cannot Be Edited


Created By: Shannan Hansen On 10/17/2023 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AVERY LANE
FACILITY NUMBER: 216804130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2023
Section Cited
CCR
81075(b)

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81075 Health-Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

***This requirement has not been met as evidenced by:
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Facility to provided document of when and what training is to be conducted by 10/18/2023 and provide proof of medical training for involved staff, to be completed with signed, dated documents after training by 10/23/2023. Program Director has put additional safety measures in place.
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LPA's record review and interview with Program Director revealed 3 clients (C1,C2, &C3) were not given some of their medications on 10/16/2023. C1 & C3 missed their noon medication and C2 missed one of their morning medications. This is an immediate risk to the health and safety of clients 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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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