286804120-8-8-2023-21-AS-VBEI-CUHU4B-20230808151453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804120
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:14:59 PM

Document Has Been Signed on 08/08/2023 03:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	RAMEILS SACRED CARE HOMES 1		FACILITY NUMBER:	286804120
ADMINISTRATOR:	JEFFERSON, JENERO		FACILITY TYPE:	735
ADDRESS:	1509 RIO GRANDE		TELEPHONE:	(310) 531-6049
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	95403
CAPACITY: 6		CENSUS: 4	DATE:	08/08/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	House Manager, Rowena Radana		TIME COMPLETED:	01:16 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) Victoria Bertozzi arrived unannounced to conduct a Post Licensing inspection and was greeted by House Manager, Rowena Radana. Administrator, Jenero Jefferson arrived later but was unable to stay for entire inspection so gave permission for House Manager to sign report. LPA initiated a tour of the facility around 10:30am and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. There was one client in facility during inspection and three others at their day program. Water temperature in clients' bathroom measured at 117 degrees F which is within allowable range of 105 to 120 degrees F. Cabinet containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last serviced May 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular disaster drills and the most recent drill was conducted June 2023. Facility does not currently have an emergency supply of water to meet the requirement of Health and Safety Code 1565(a)(2). Twelve staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. One of twelve staff are not associated to the facility. Medications and medication records were reviewed as well as client P&I. Review of facility's Surety Bond showed that client P&I exceeds the amount covered by the Surety Bond. Staff and resident files have not been updated since the recent Change of Ownership. Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RAMEILS SACRED CARE HOMES 1	FACILITY NUMBER: 286804120
	VISIT DATE: 08/08/2023

NARRATIVE

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Continued from LIC809

Three out of four clients in care are over the age of 59 which is more than fifty percent of the census. Facility must request an exception and was given information on the exception process.

Documents needing to be updated include, but are not limited to, the following:

Clients' Admission Agreements
Proof of staff training
All staff employment documents showing previous Licensee
Surety Bond and LIC400 to reflect accurate amount of cash that is being safeguarded

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.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2023 03:14 PM - It Cannot Be Edited

Created By: Victoria Bertozzi On 08/08/2023 at 02:26 PM

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: RAMEILS SACRED CARE HOMES 1	FACILITY NUMBER: 286804120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(2)

80019(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of twelve staff] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Administrator agrees to have noted staff associated to facility no later than POC due date, 8/9/2023.

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:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Victoria Bertozzi

LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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