<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236800970
Report Date: 06/28/2024
Date Signed: 06/28/2024 12:50:02 PM


Document Has Been Signed on 06/28/2024 12:50 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:OBSERVATORY CARE HOMEFACILITY NUMBER:
236800970
ADMINISTRATOR:CRISTINA ALCASIDFACILITY TYPE:
740
ADDRESS:270 OBSERVATORY STREETTELEPHONE:
(707) 468-5986
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:6CENSUS: 1DATE:
06/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Eliseo AlcasidTIME COMPLETED:
01:00 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
During the course of a complaint investigation, Licensing Program Analyst (LPA) Chris Arnhold reviewed resident files and observed facility did not notify the Department of a death of a resident in March 2024. LPA reviewed reporting requirement regulation with Licensee and provided a copy.

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.

This report was reviewed with Licensee and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/28/2024 12:50 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: OBSERVATORY CARE HOME
FACILITY NUMBER: 236800970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87211(a)(1)(A)

1
2
3
4
5
6
7
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any...(A) Death of any resident from any cause regardless
1
2
3
4
5
6
7
Licensee to review regulation provided by LPA and submit self certification that the regulation will be followed going forward. Self certification to be submitted by POC date of 07/05/2024.
8
9
10
11
12
13
14
of where the death occurred...This requirement is not met as evidenced by: Based on record review, Licensee did not send a written death report after the death of a resident.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2