486801461-3-4-2025-21-AS-JFLO-DEG3CL-20250304170806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801461
Report Date: 03/04/2025
Date Signed: 03/04/2025 05:08:14 PM

Document Has Been Signed on 03/04/2025 05:08 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:	DANA'S FAMILY HOME		FACILITY NUMBER:	486801461
ADMINISTRATOR/ DIRECTOR:	THOMAS, DANA		FACILITY TYPE:	735
ADDRESS:	855 PALERMO DR.		TELEPHONE:	(707) 438-7397
CITY:	SUISUN	STATE: CA	ZIP CODE:	94585
CAPACITY: 4		CENSUS: 4	DATE:	03/04/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Dana Thomas, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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At approximately 1:50 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Annual Continuation inspection and was greeted by staff. Dana Thomas, Administrator was contacted via telephone and arrived at approximately 2:45 PM. Facility is an Adult Residential Facility with four (4) ambulatory clients in care. Two (2) clients were present during today's visit and two (2) were away at Day Program.

At approximately 2:00 PM, LPA began file review. Four (4) staff files were re viewed and each contained the required documents per regulation. However, Staff 1 (S1) was observed missing their health screening and Staff 2 (S2) was observed missing proof of negative TB results, (see LIC809D). All staff files reviewed contained proof of current CPR and First Aid training. Four (4) client files were reviewed and contained the required documents. Administrator agreed to ensure that all documents are signed by the clients' responsible party and all of the required documents are in every client file moving forward in order to bring the facility into compliance with regulation.

At approximately 3:30 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. However, LPA observed one medication for Client 1 (C1) ran out a few days ago and Client 2 (C2) was not given one of their medications on two instances during the last month, (see LIC809D). P&I money and logs were inspected and all were observed stored and maintained in compliance with regulation.

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

LIC500 Personnel Report (updated)
LIC809D Emergency Disaster Plan (updated)

Continued on LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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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Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited

Created By: Julie Florio On 03/04/2025 at 04:46 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: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 4 personnel files reviewed where S1 was observed missing a health screening and S2 was observed missing proof of negative TB results which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Administrator will submit proof of S1's completed health screening and S2's negative TB results to CCL by POC dues date 04/04/2025.

Type B

Section Cited

CCR

80075(b)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out 4 client files reviewed where one of C1's medications ran out and C2 was not given one of their medications on two instances throughout the month which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Administrator to submit a self-certification to CCL that they will personally oversee medication ordering and tracking to ensure the facility operates in compliance moving forward to CCL by POC due date 04/04/2025.

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: 03/04/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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: DANA'S FAMILY HOME	FACILITY NUMBER: 486801461
	VISIT DATE: 03/04/2025

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Continued from LIC809...

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, or repeat violations within a 12 month period, may result in a civil penalty assessment.

Exit interview conducted with Administrator, whose signature on form confirms receipt. Appeal rights provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

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