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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801461
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:54:28 PM

Document Has Been Signed on 01/12/2023 02:54 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:DANA'S FAMILY HOMEFACILITY NUMBER:
486801461
ADMINISTRATOR:THOMAS, DANAFACILITY TYPE:
735
ADDRESS:855 PALERMO DR.TELEPHONE:
(707) 438-7397
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Dana ThomasTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) K Walters arrived at this facility unannounced, to conduct an Annual Required 1 year inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Staff, Lexie Wilridge. The Administrator Dana Thomas arrived later. There are currently 4 clients residing in the facility and they receive services from North Bay Regional Center. The facility operates with 24 hour staffing.

LPA toured the facility with staff and made the following observations: LPA observed signs posted to promote droplet precaution at the entrance of the facility. There was also a sign-in sheet with a questionnaire for visitors and a thermometer to check visitors and client temperatures. There was at least a 30 day supply of Personal Protective Equipment and Incontinence Products.

Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be charged and inspected 12/23/2022. The carbon monoxide and smoke detectors were tested. The smoke detectors were inoperable, however all of the carbon monoxide detectors were working. LPA observed that the toxins that were stored under the sink were not locked and were accessible to clients in care. In addition the medication cabinet was unlocked and accessible. The Administrator stated that they will replace the lock on the medication and toxins cabinet. LPA consulted with facility regarding the right yard gate that needs to be adjusted so it latches easily.

Continued onto LIC 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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: DANA'S FAMILY HOME
FACILITY NUMBER: 486801461
VISIT DATE: 01/12/2023
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At the time of inspection LPA observed that Client C1, was locked inside of their bedroom, that was only able to open using a key. Due to physical and mental limitations, C1 was unable to unlock the door an exit the room without staff's assistance. Interviews with staff reveal that C1's bedroom door was locked to prevent client C2 from entering their room without permission. Administrator and LPA discussed them removing the lock and adding an auditory alarm to alert staff of C2 entering C1's bedroom. LPA toured the exterior portion of the facility and observed that the deck was slippery with moss due to the recent rainfall. Administrator agreed to either remove deck or clean the deck to ensure that the environment is safe for clients and du send pictures to LPA.

LPA is requesting that the Administrator provide Community Care Licensing with: an updated copy of their LIC 500, Smoke Detector testing date document(s),
Surety Bond

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights was emailed along with this report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2023 02:54 PM - It Cannot Be Edited


Created By: Katrina Walters On 01/12/2023 at 01:53 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: DANA'S FAMILY HOME
FACILITY NUMBER: 486801461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2023
Section Cited

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Based on observation, record review and interviews, facility did not ensure personal rights were ensured when C1 was unable to exit and unlock their bedrooom door. This posed a personal rights risk to persons in care.
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Type A
01/16/2023
Section Cited

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidenced by:
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Based on observation Facility did not ensure this requirement was met when the cabinents to medication and chemicals were left unlocked. This poses an immediate health and safety risk to residents in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2023 02:54 PM - It Cannot Be Edited


Created By: Katrina Walters On 01/12/2023 at 02:18 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: DANA'S FAMILY HOME
FACILITY NUMBER: 486801461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2023
Section Cited

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80020(a) Fire Clearance - All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. ** This requirement has not been met as evidenced by:
Based on observations LPA found smoke
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were inoperable. This poses a health and safety risk to clients in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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