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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803243
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:38:17 PM

Document Has Been Signed on 12/05/2024 03:38 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:CAREBESTFACILITY NUMBER:
486803243
ADMINISTRATOR/
DIRECTOR:		ZHANG, GUOLIANFACILITY TYPE:
735
ADDRESS:2376 BURGUNDY WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: DATE:
12/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow-up visit regarding an incident report received by CCL on 10/11/2024 from a client's Day Program and was greeted by Staff 1 (S1). Licensee was contacted via telephone and informed LPA that the client resides at their other care home, Care Great.

However, upon entering the facility, LPA immediately observed a single sized mattress and box spring on the floor made up with sheets and a pillow in the living room directly off of the entryway, (see LIC809D). LPA informed Licensee that they cannot have a bed there or in any common area of the facility. Licensee stated that it is for overnight staff and asked where they could sleep then? LPA advised Licensee that staff shall not sleep in any resident bedroom, common are, the garage or any un-permitted structures. Licensee agreed to remove the bed tomorrow and send LPA pictures.

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 S1 and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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Document Has Been Signed on 12/05/2024 03:38 PM - It Cannot Be Edited


Created By: Julie Florio On 12/05/2024 at 03:23 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: CAREBEST
FACILITY NUMBER: 486803243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2024
Section Cited
CCR
85087(a)(3)

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 85087(a)(3) Buildings and Grounds:
No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
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Licensee agreed to remove the bed 12/6/2024 and send LPA picture proof to CCL by POC due date 12/9/2024.
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LPA observed a single sized mattress and box spring on the floor of the living room just off of the facility's entry way and it was made up with sheets and a pillow. This poses a personal rights violation 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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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