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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111090
Report Date: 05/10/2023
Date Signed: 05/11/2023 01:19:46 PM

Document Has Been Signed on 05/11/2023 01:19 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:GILCREST GROUP HOME, THEFACILITY NUMBER:
480111090
ADMINISTRATOR:CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:447 GILCRESTTELEPHONE:
(707) 563-5543
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 9CENSUS: 5DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Cheryl Davidson, AdministratorTIME COMPLETED:
12:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with staff, Mila Moises, Administrator, Cheryl Davidson arrived a few minutes later. There is currently 7 clients in care and this facility is licensed for a total capacity of 9 Ambulatory clients, no approval for non-ambulatory or bedridden clients.

LPA toured facility and grounds with Care staff, Mila Moises and observed the home be at a comfortable temperature with all exits free from obstruction. Some clients rooms require a reading lamp. Water temperature in bathrooms used by residents measured at 119 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. LPA went over issues with the water pressure in the rear hall shower not operating correctly and not delivering enough water. Extra hygiene products and linens were available. Cabinet in staff room containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications are centrally stored and locked. Emergency food and water supplies are stored in office. Facility has smoke detectors located throughout the facility as well as a Carbon Monoxide detector that were operational during inspection. Most recent disaster drill was conducted March 2023. Fire Extinguishers were found to be last charged and serviced on June 22,2022.

Three staff files and resident files were reviewed and S1 was missing proof of health screening . Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Cheryl Davidson is active.


Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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: GILCREST GROUP HOME, THE
FACILITY NUMBER: 480111090
VISIT DATE: 05/10/2023
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Continued from LIC809

LPA went over clothes dryer that is in the process of being fixed and facility is waiting for a part. The downstairs living room requires a new ceiling light that is operational. In addition LPA went over facility doing a thorough cleaning of the entire facility and bathrooms floors and walls. Bathroom located in clients room C1 needs a new toilet seat, as the seat was partially hanging. LPA consulted and facility will notify LPA as each item corrected.

Licensee and LPA discussed the Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit copies of the following documents by 6/9/2023:



LIC9020 Register of Clients
LIC 500 Personnel Summary
LIC 308 Designation of Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)



Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, whose signature below confirms receipt of report.
Due to printer issues, this report was emailed to Administrator. Appeal Rights Provided

Exit interview conducted with Cheryl Davidson
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2023 01:19 PM - It Cannot Be Edited


Created By: Araceli Canela On 05/10/2023 at 11:55 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: GILCREST GROUP HOME, THE
FACILITY NUMBER: 480111090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs inspection today with staff S2, the licensee did not comply with the section cited above in 4 out of 7 client bedrooms did not have a lamp available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Facility will send in proof all clients rooms have a lamp available in their room.
POC due date 6/9/2023 to LPA Araceli Canela
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs records reviewed during todays inspection with administrator, Cheryl Davidson, some staff did not have proof of a health screening available in their file, the licensee did not comply with the section cited above in 1 out of 3 staff files that were reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Facility to send in written plan they understand requirements and how they will ensure all staff have the required health screening and send proof of S1's health screening to LPA.
POC due date 6/9/2023 to LPA Araceli Canela
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:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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