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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801829
Report Date: 11/24/2021
Date Signed: 11/24/2021 06:31:20 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:CHOCTAW HOUSE NORTHFACILITY NUMBER:
286801829
ADMINISTRATOR:HAHKLOTUBBE, JULIETFACILITY TYPE:
740
ADDRESS:2529 VINE HILL COURTTELEPHONE:
(707) 265-8722
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
11/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Juliet Hahklotubbe, LicenseeTIME COMPLETED:
06:45 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) Lopez conducted an unannounced Case Management-Other visit. LPA met with staff and Licensee, Juliet Hahlotubbe arrived later.

LPA toured facility with Licensee. During facility tour, LPA inspected all three restrooms in facility. LPA measured hot water in all restrooms. Hot water measured 132.8, 137.3, and 155.0 degrees F. Facility understands that hot water temperature has to measure 105 degrees F to 120 degrees F.

During the review of staff records LPA observed that S1 was not associated to facility. Licensee stated that S1 has been working since 11/15/21. S1 is does work daily in facility. Licensee agrees to submit transfer for S1.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.


***Civil Penalties in the amount of $300 were issued during today’s visit due to required individual not having proper Fingerprint clearance and/or association to the facility.

Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
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 2
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 NORTH
FACILITY NUMBER: 286801829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2021
Section Cited

1
2
3
4
5
6
7
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature...shall be maintained to automatically regulate the temperature of hot water used by residents...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This has not been met as evidence by:
8
9
10
11
12
13
14
LPA measured hot water temperature for all three restrooms in facility which are used by residents. Hot water measured 132.8, 137.3, and 155.0 degrees F. Facility understands that hot water temperature has to measure 105 degrees F to 120 degrees F.
8
9
10
11
12
13
14
Type A
11/26/2021
Section Cited

1
2
3
4
5
6
7
(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: (2) Request a transfer of a criminal record clearance ...This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interview and review of record. LPA learned that S1 was determined to have been working in the facility since 11/15/21 and was not associated to facility which poses an immediate health and safety risk to residents in care. ***Immediate Civil Penalties in the amount of $300 were issued during today’s visit.
8
9
10
11
12
13
14
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: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2