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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102469
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:24:35 PM

Document Has Been Signed on 02/16/2023 01:24 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:CLARK-RO HOMEFACILITY NUMBER:
480102469
ADMINISTRATOR:SKILLMAN, C.W. & R.LFACILITY TYPE:
735
ADDRESS:242 CORTLANDTELEPHONE:
(707) 642-9361
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 2DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Tracy Skillman, House ManagerTIME COMPLETED:
01:40 PM
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On 2/16/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with House Manager Tracy Skillman. The facility currently provides care for 2 clients both of which were on personal outings or work at the time of visit.

LPA continued with a tour of the facility with House Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the hallway were found to be last charged on 6/9/2022 at the time of the visit. Smoke and carbon monoxide detectors in client bedrooms and throughout the facility were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinets located in the laundry room and garage both found to be secured. There was a supply of hygiene products and paper products available upon client request. Facility has restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in the staff office and found to be secured. During a tour of the backyard, LPA observed a downed electrical power line leading from the corner of the fence leading to the facility. Wire is exposed and accessible and is an immediate health and safety risk to clients in care. LPA was informed that PG&E had conducted power line maintenance and had trimmed a tree in contact with the electric tower in January of 2023. Licensee to contact PG&E immediately to schedule repairs.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLARK-RO HOME
FACILITY NUMBER: 480102469
VISIT DATE: 02/16/2023
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Case Management:
LPA Tobola conducted additional case management regarding recent incident reports of client (C1) not following house policies of returning from outings in a timely manner. LPA found that C1 is allowed to leave the facility unassisted and with this behavior recorded in the past. LPA informed that staff and Licensee are working with C1 for better communication on C1's whereabouts when on outings. No deficiencies cited under case management.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.

LPA requested the following documents be sent to CCL by COB 3/2/2022:



LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2023 01:24 PM - It Cannot Be Edited


Created By: Dominic Tobola On 02/16/2023 at 12:58 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: CLARK-RO HOME
FACILITY NUMBER: 480102469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 exposed and accessible electrical power line located in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee agrees to contact PG&E or appropriate company and schedule repairs to downed power line located in the facility backyard. Licensee to schedule appointment and notify CCLD by POC due date 2/17/2023. In addition, Licensee is to submit photo proof of evidence showing completed repairs by POC due date 2/23/2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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