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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800768
Report Date: 06/28/2024
Date Signed: 06/28/2024 01:41:22 PM

Document Has Been Signed on 06/28/2024 01:41 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:PENNSYLVANIA CARE HOMEFACILITY NUMBER:
486800768
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:2055 PENNSYLVANIA AVENUETELEPHONE:
(707) 438-0267
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Patricia Bucal, House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Emlyn (Mimi) Goco, DSP. House Manager, Patricia Bucal was contacted and arrived shortly after. Facility is an Adult Residential Facility with four (4) ambulatory clients in care. LPA was informed that one (1) client left for Day Program; three (3) clients were present during visit.

At approximately 10:00 AM, LPA initiated a tour of the facility with House Manager and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered patio and seating area in the backyard with outdoor space for activities. LPA observed an activity schedule and a facility computer available for client use. Facility has internet available to clients in care and the phone was tested an operational.

Facility's fire extinguisher was observed charged and was last serviced May 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular quarterly disaster drills, and the most recent drill was conducted April 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated January 2024. LPA observed a supply of PPE, emergency supplies, and a first aid kit. LPA advised, and House Manager agreed, to purchase flashlights for emergency preparedness. Administrator states the facility does not have a backup generator.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
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: PENNSYLVANIA CARE HOME
FACILITY NUMBER: 486800768
VISIT DATE: 06/28/2024
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Continued from LIC809...

At approximately 10:45 AM, LPA reviewed four (4) staff files and four (4) client files. Four (4) of four (4) staff files reviewed have the required paperwork. Three (3) of four (4) staff have the required proof of First Aid certificate. House manager assured LPA facility will provide proof of First Aid certification for the 4th staff member who was just hired. Each staff file reviewed has current CPR certification. Facility had the required paperwork in all client files reviewed. House Manager coordinates medical and dental visits for the clients and take them to their appointments.

At approximately 11:50 AM, LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

At approximately 12:10 PM, LPA discussed recent incident reports (IRs), dated 6/9, 6/16, 6/24, submitted by House Manager to CCLD, and an email and text message attachment sent to North Bay Regional Center (NBRC) on 6/26, by House Manager in regards to client (C1) aggressive and threatening behaviors escalating.

No deficiencies cited during today's inspection. Exit interview conducted with House Manager. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
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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