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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800164
Report Date: 05/17/2024
Date Signed: 05/17/2024 12:00:25 PM

Document Has Been Signed on 05/17/2024 12:00 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 RESIDENTIAL CARE IIFACILITY NUMBER:
486800164
ADMINISTRATOR/
DIRECTOR:		SKILLMAN, ROSIE L.FACILITY TYPE:
735
ADDRESS:1234 LOUISIANA STREETTELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 1DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Judy Johnson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 5/17/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Judy Johnson. The facility currently provides care for 1 client, one of which were present at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 2/9/2024. Smoke and carbon monoxide detectors found throughout the facility, tested and to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients were measured between 110.4 and 113.1 degrees F which is within Title 22 Regulations. Facility conducts and records emergency disaster drills quarterly.

Client admitted currently does not take medications. There is a secured storage in the staff quarters accessible to all staff that is prepared for medication storage upon need. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed client record and found that the facility is missing client, C1's Physician's Report and updated Individual Program Plan (IPP) and Appraisal Assessment. LPA informed that North Bay Regional Center has vendorized the client placement and currently working on obtaining C1's physician's report and in the process of amending C1's IPP. C1 is scheduled for a physician's exam in July due to physician unavailability. Administrator and LPA contacted C1's primary care provider and scheduled a walk-in appointment for a tuberculosis exam. LPA informed that C1 had transitioned from a family home and was recently assigned a new primary care provider this past month. LPA found Administrator to address need of assessments and records in an appropriate manner considering constraints. Technical Violations Issued.

There is a sufficient supply of linens, hygiene product and paper products available for client use. Items that could pose danger to client if accessible were found to be secured. Client was observed to have a positive relationship with staff and found participating in personal activities during the visit.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLARK-RO RESIDENTIAL CARE II
FACILITY NUMBER: 486800164
VISIT DATE: 05/17/2024
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Rosie Skillman and Judy Johnson have both submitted their re-certification training documents and waiting for pending list. Administrator, Judy Johnson indicated that they've spoken with the Certification Unit and informed of the current delay.

LPA requested the following documents be sent to CCL by COB 5/31/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership/Control of Property

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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