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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803251
Report Date: 01/19/2024
Date Signed: 01/19/2024 06:30:48 PM


Document Has Been Signed on 01/19/2024 06:30 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:MASONIC GUEST HOME IIFACILITY NUMBER:
486803251
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:108 PINTO DRIVETELEPHONE:
(707) 644-3822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Leonida LacapTIME COMPLETED:
05:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with Licensee, Leonida Lacap. During a complaint investigation LPA discovered resident R1 recently walked out of the facility, went to a neighbors home and requested the police was called. Facility also stated they called the police regarding R1 not wanting to return to the facility and being upset and yelling.
LPA will review and get additional information regarding the incident.
The facility failed to report incident to Community Care Licensing and to R1's physician as required. LPA will review incident and return to issue any citations warranted.

LPA went over hallway bathroom that had no toilet paper and licensee explained they were told they can provided each resident with two rolls of toilet paper per month and each resident has their own. Per statements received, facility expects residents to purchase their own toilet paper if they go over two rolls. LPA went over facility requirements to supply residents with the required toilet paper. An advisory note was issued to facility, failure to correct may result in facility being cited under regulation: 87307(a)(3)(D) Personal Accommodations and Services.
LPA also once again went over master bedroom bathroom and that resident R2 and R3 can use their bedroom bathroom and this is not for staff to use. A previous Advisory note was issued to this facility regarding this matter.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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 01/19/2024 06:30 PM - It Cannot Be Edited

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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2024
Section Cited
CCR
87211(a)(D)

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87211(a)(D)Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Facility to send in written plan of correction on how they will ensure they stay in compliance and submit incident report to LPA Canela
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This requirment was not met as evidenced by: during todays inspection, it was disclosed resident R1 walked out of the facility to a neighbor, was upset and yelling and asked they call the police. Facility failed to report to CCL and notify R1s physician. This is a potential risk to the health and safety of residents in care.
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POC due date 1/24/2024

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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