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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800991
Report Date: 09/20/2021
Date Signed: 09/21/2021 07:52:18 AM

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:CHOCTAW HOUSEFACILITY NUMBER:
286800991
ADMINISTRATOR:HAHKLOTUBBE, JULIEFACILITY TYPE:
740
ADDRESS:2504 REDWOOD ROADTELEPHONE:
(707) 258-9348
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Madona Martinez - Ass. AdministratorTIME COMPLETED:
01:15 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
Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Ass. Administrator Madonna Martinez. Facility has 6 residents present with no residents under Hospice care at this time. Facility offers activities coloring, reading, exercises, outside walk, and etc.

During facility tour on 9/20/2021 with Ass Administrator Madonna Martinez, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was last charged on 2/2021. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Dangerous items were stored inaccessible to residents in locked in a cleaning supply closet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Facility understands that hot water temperatures must measure within Title 22 acceptable regulations of 105 to 120 degrees F.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Facility has some posters that have been placed at facility. At this time facility is planning to have at entrance a table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the facility storage/garage room. Facility has hired and admitted new residents and staff since COVID-19. Facility has a new staff S1 who started today at the facility, however; staff S1 hasn’t been fingerprint cleared and/or associated to the facility. (LIC 809-D, Civil Penalty) Department is providing facility with the following Regulations: #87355 Criminal Record Clearance; H&S Code #1569.625 Staff Training; #87412 Personnel Records; H&S Code #1569.618 Administration & Management of RCFEs; and #87411 Personnel Req. General.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: CHOCTAW HOUSE
FACILITY NUMBER: 286800991
VISIT DATE: 09/20/2021
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
26
27
28
29
30
31
32
Residents medications are stored and locked in a locked medication closed in the storage/garage. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are sometimes able to wear masks when going on outings. All staff had masks on during this visit.
In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available video and telephone calls when contacting with family members and others. Staff had all PPE training required on file and facility is working towards obtaining N-95 fit testing.

Furthermore LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).

LPAs reviewed Licensing Information System (LIS) with staff who stated that is correct and updated at this time. However, LPA learned that there is a change of ownership (CHOW) occurring and documentation still pending from Licensee Julie for facility closure/CHOW with the Department.



Immediate Civil Penalties are being assessed in the amount of $500 due to staff not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $500.00

Appeal of Rights Given.

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.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: CHOCTAW HOUSE
FACILITY NUMBER: 286800991
VISIT DATE: 09/20/2021
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
26
27
28
29
30
31
32
Department is requesting the following updated documents to be submitted to CCLD by 9/27/2021:

LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: CHOCTAW HOUSE
FACILITY NUMBER: 286800991
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above in 1 out of 2 staff fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.LPA interviewed Ass Adm & observed that staff S1started working on 9/20/21,however has no fingerprint clearance &/or is associated to the facility at this time.(CP)
POC Due Date: 09/21/2021
Plan of Correction
1
2
3
4
Facility to ensure that all staff is fingerprint cleared and associated to the facility before working in a licensed facility. Facility to submit a self certification LIC 9098 as proof that staff S1 and no other staff who is not fingerprint cleared & associated to the facility is working at the facility by POC date of 9/21/2021 to the Department.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 10