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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480109899
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:06:42 PM

Document Has Been Signed on 06/02/2022 12:06 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:HARRISON HOME CAREFACILITY NUMBER:
480109899
ADMINISTRATOR:HARRISON, WILMAFACILITY TYPE:
735
ADDRESS:390 SAWYER STREETTELEPHONE:
(707) 643-4853
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Mario Gray, House ManagerTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by House Manager, Mario Gray (MG). The facility currently provides care for 5 clients, 4 of which were present and 1 of which out in the community at the time of visit.

LPA arrived at the facility and had temperature checked and logged. 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 was found to be expired and last charged on 4/23/2021 at the time of 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. Toxins are stored in a locked cabinet in the facility kitchen and secured staff restroom. LPA tested all facility smoke alarms and found them to be in working condition. Medications are kept in a secured cabinet located in the kitchen. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. LPA found all facility staff requiring 1st Aid & CPR re-certification.

During the inspection LPA Tobola observed facility side yard gate to be detached to the fence. House Manager explained that the neighbor often locks themselves out of the house and has broken the fence several occasions to access their shared side yard. LPA issued Technical Violation and House Manager agrees to provide proof of corrections for the fence repair.


Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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: HARRISON HOME CARE
FACILITY NUMBER: 480109899
VISIT DATE: 06/02/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. All clients and staff are vaccinated and boosted with no symptoms. Staff and residents received rapid COVID testing every week with tests provided by pharmacy. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms based on changes of condition.

LPA requested the following documents be sent to CCL by COB 6/9/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2022 12:06 PM - It Cannot Be Edited


Created By: Dominic Tobola On 06/02/2022 at 11:20 AM
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: HARRISON HOME CARE
FACILITY NUMBER: 480109899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 expired fire extinguishers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee failed to follow Fire Marshal fire clearance regulations, the fire extinguisher was last charged 4/23/2021 and expired and can pose a potential health & safety risk to clients in care. Licensee agrees to have fire extinguisher inspected/charged and up to date. Licensee to submit photo proof of corrections to CCLD by POC due date 6/9/2022.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 expired CPR & 1st Aid Certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee failed to ensure all staff have required 1st Aid Training on file. Licensee agrees to schedule re-certification training with a licensed vendor by POC due date 6/9/2022. In addition, Licensee is to submit proof of updated 1st Aid & CPR certificates by POC due date 6/16/2022.
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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
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