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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 12/21/2021
Date Signed: 12/21/2021 06:03:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CEDARS CARE HOME, THEFACILITY NUMBER:
286800667
ADMINISTRATOR:LOPEZ, PAULINAFACILITY TYPE:
740
ADDRESS:1520 CEDAR STREETTELEPHONE:
(707) 942-9200
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:12CENSUS: 9DATE:
12/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Paulina Lopez, AdministratorTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Paulina Lopez and House Manager, Viridiana Agapoff . The purpose of this case management inspection was to obtain additional information regarding a self reported incident submitted to Community Care Licensing (CCL) on 10/13/21, 12/12/21 and 12/22/21.

On 10/20/21 CCL received an incident report reporting an unwitnessed fall. Administrator stated that they believe that Staff #1 (S1) was sleeping on shift. S1 is no longer working with facility according to Administrator. Facility had staff training regarding unwitnessed falls. LPA was given a copy of proof of all staff training and additional documentation.

On 12/12/21 and 12/22/21, Resident #1 (R1) was having behavioral issues. Facility contacted physician multiple times for guidance. According to Administrator, R1 is now doing better. LPA requested documentation and conducted interviews. Facility will request a new physician report from physician.

Exit interview conducted with Administrator, Paulina Lopez. Report given.

No deficiencies cited today.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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