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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801416
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:04:06 PM

Document Has Been Signed on 08/02/2024 03:04 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:INFANTE FAMILY HOME, INC.FACILITY NUMBER:
486801416
ADMINISTRATOR/
DIRECTOR:		INFANTE, CECILIAFACILITY TYPE:
735
ADDRESS:1931 DIAMOND WAYTELEPHONE:
(707) 319-8744
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Charmaine Infante, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 9:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by a facility caregiver. Charmaine Infante, House Manager, was contacted and arrived shortly after. Facility is an Adult Residential Facility with four (4) ambulatory clients in care. LPA was informed that three (3) clients left for Day Program; one (1) client was present during visit.

At approximately 9:45 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. The living room ceiling was observed with cracks present: one situated in the joint where the ceiling and wall meet which is approximately 3 feet long, and the other is water stained, approximately 5 feet long, and extending perpendicular off of the previously mentioned crack towards the center of the ceiling. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed two light bulbs burned out in one client bathroom and one in the other client bathroom. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and LPA observed a damaged curtain rod in one bedroom and two bedrooms without lighting. House Manager states this is due to the two clients in these rooms exhibiting documented destructive behaviors as noted in their IPPs. House Manager and IPP state lights were removed for the safety of these two clients. LPA observed the client bedrooms to contain all of the remaining appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. However, LPA observed three bottles of laundry detergent on the dresser in a staff bedroom. House Manager had staff lock the detergent away in the facility laundry area. LPA advised House Manager to ensure all cleaning supplies, detergents, and chemicals remain inaccessible to clients at all times. Facility has at least two days of perishable food and a supply of non-perishable foods. LPA advised House Manager to increase emergency food and water supply to ensure facility can sustain all clients in care for 7 days if needed.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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: INFANTE FAMILY HOME, INC.
FACILITY NUMBER: 486801416
VISIT DATE: 08/02/2024
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Continued from LIC809...

Medications were centrally stored and locked. There is a sun room with a seating area and outdoor space for gardening and activities. LPA observed an activity schedule and a facility computer available for client use. Facility has internet available to clients in care, and the facility phone was tested an operable.

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, with the most recent drill conducted April 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated July 2023. LPA observed a supply of PPE, emergency supplies, a first aid kit, and a backup generator.

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 and proof of current first aid certificate. Four (4) of four (4) resident files reviewed contained all of the required paperwork. House Manager coordinates medical and dental visits for the clients and takes them to their appointments.

At approximately 1:15 PM, 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. Facility's surety bond is in the proper amount and is valid through June 2027.

LPA was informed that House Manager has administrator certificate and Licensee plans to appoint House Manager as new Administrator. LPA advised House Manager to ensure facility submits the required paperwork to CCL for processing.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC610- Emergency Disaster Plan (updated)
LIC 308 Designation of Facility Responsibility

continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2024 03:04 PM - It Cannot Be Edited


Created By: Julie Florio On 08/02/2024 at 02:29 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: INFANTE FAMILY HOME, INC.
FACILITY NUMBER: 486801416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 ensuring facility is in good repair as evidenced by threeburned out light bulbs in client restrooms, a damaged curtain rod in one client room, and a roof leak and cracked ceiling with water stains present which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2024
Plan of Correction
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House Manager to submit proof of new light bulbs installed and working, the window covering in client bedroom is in good repair, and the roof leak has been repaired to CCL by POC due date 9/2/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


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: INFANTE FAMILY HOME, INC.
FACILITY NUMBER: 486801416
VISIT DATE: 08/02/2024
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continued from LIC809C...

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.

Exit interview conducted with House Manager and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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