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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480109899
Report Date: 06/28/2024
Date Signed: 06/28/2024 01:51:18 PM

Document Has Been Signed on 06/28/2024 01:51 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:HARRISON HOME CAREFACILITY NUMBER:
480109899
ADMINISTRATOR/
DIRECTOR:		HARRISON, WILMAFACILITY TYPE:
735
ADDRESS:390 SAWYER STREETTELEPHONE:
(707) 643-4853
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mario Gray, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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At approximately 9:00 AM, Licensing Program Analyst (LPA) Mutialu conducted an unannounced Annual Required inspection to this facility and met with Mario Gray, House Manager (HM). At approximately 9:10 AM, LPA and HM toured the building and grounds which was found to be clean and in good repair but undergoing renovation. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins were not secure HM was in the middle of cleaning. Medication is centrally stored but not secure HM was in the process of rearranging medication storage due to ongoing renovations. There is a sufficient supply of hygiene products and linens on hand for client use. Five out five clients rooms were inspected and found to be within regulation. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 114 and 115 degrees F at faucets accessible to clients. Six out of six smoke detectors and one out of one smoke/carbon monoxide combo detector were found to be in working order. One out of one fire extinguishers were fully charged and inspected in 2024. Disaster Drills are conducted quarterly with the last drill conducted 4/1/2024.


At approximately 10:30 AM, LPA reviewed 5 of 5 Client records which four out five client records were found to be missing Needs and Services Plans, 1 out of 5 client records were found to be missing LIC602-Medical Assessment, and 5 out of 5 client records were found to be missing LIC613- Peronal Rights. LPA reviewed 3 out of 3 staff records which were found to have all required documentation. First aid and CPR certification were expired as of 06/24/2024 in 3 of 3 staff files reviewed. Administrator's Certificate is expired. Administrator, Wilma Harrison to provided proof to CCLD of recertification submission and course completion as well as letter requesting update of recertification processing.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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: HARRISON HOME CARE
FACILITY NUMBER: 480109899
VISIT DATE: 06/28/2024
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Continued from 809


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan (updated with non-local evacuation site)
LIC613 -Personal Rights - (signed)
Client Roster
Proof of Administrator Recertification documentation


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.

This report was reviewed with Mario Gray and Appeal rights were given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2024 01:51 PM - It Cannot Be Edited


Created By: Stefanie Mutialu On 06/28/2024 at 01:03 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: HARRISON HOME CARE
FACILITY NUMBER: 480109899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 staff records have expired First Aid Certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2024
Plan of Correction
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Administrator to submit new CPR/First Aid Training/Certification and facility training plan/process to ensure all training including First Aid is current and up to date to CCLD by POC due date
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2024
Plan of Correction
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Administrator to submit current Need and Services Plans for 5 out of 5 clients and plan/process to ensure Needs and Services Plans are kept up to date to CCLD by POC due date .
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
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