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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803302
Report Date: 09/14/2023
Date Signed: 09/14/2023 05:48:45 PM

Document Has Been Signed on 09/14/2023 05:48 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:WILLIAMS BOARD & CARE HOMEFACILITY NUMBER:
486803302
ADMINISTRATOR:WILLIAMS, KATRINAFACILITY TYPE:
735
ADDRESS:430 FORDHAM DRIVETELEPHONE:
(707) 652-2445
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Margaret Henley, CaregiverTIME COMPLETED:
06:55 PM
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On 9/14/2023 LPA Carol Fowler arrived at the facility to conducted a required 1 year Visit. LPA arrived at the facility at approximately 1:00pm and was greeted by client C1 sitting in the front yard, C1 escorted LPA into the facility and C2 was sitting in the living room watching television. C2 knocked on Caregivers bedroom door and there was no answer. C3 came from the back and told LPA that the Caregiver made a run and she will be back soon. LPA informed C1, C2 and C3 that LPA will be waiting outside in the car. LPA called the Administrator and was told staff should be at the facility and she is out of town. Administrator called staff and returned LPA call and informed LPA staff should be at the facility soon. LPA contacted LPM and was directed to wait until staff returns. Staff returned to the facility at approximately 1:45PM.

LPA toured facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client's bathroom measured at 106.4 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Hallway closet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. The refrigerator has locks to prevent residents from having access to food because, according to the caregiver, clients continue to go through the refrigerator, pantry and drawers, so they put locks on them. They leave out food for clients between meals. LPA observed a bowl of fruit on the table. LPA explained that if the facility wants to lock the refrigerator, they must request a waiver. Medications were centrally stored and locked.

The facility provides care for 6 clients all of which can leave the facility unassisted. However, no direct staff care or supervision was present for the 3 of 6 clients from approximately 1:00PM to 1:45PM.

Continue on LIC809
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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: WILLIAMS BOARD & CARE HOME
FACILITY NUMBER: 486803302
VISIT DATE: 09/14/2023
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CONTINUE FROM LIC809
Fire extinguisher was last inspected August, 11, 2023. Three Smoke Detectors and one Carbon Monoxide Detector were tested and operational during inspection.

LPA reviewed three staff files and three client files. Staff have required First Aid Certificates. Two of the three staff were missing their health screening. Administrator Certificate for Administrator, Katrina Williams expired on 6/20/2020.

LPA conducted a tour of the facility with the Caregiver and observed the following deficiencies
  • clients left unsupervised at the facility
  • unlocked medication on the kitchen
  • unlocked medication cabinet


***an Immediate civil penalty in the amount of $500 was issued during today's visit for 3 of 6 clients left unattended in violation of regulation 80078 Responsibility for Providing Care and Supervision.

LPA is requesting the following forms be updated and submitted to CCL by 9/21/2023:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Infection Control Plan

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

The Department will contact Licensee to schedule an in-office meeting. The Regional Center will also contact Licensee to schedule an in-person meeting. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/14/2023 05:48 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/14/2023 at 03:36 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: WILLIAMS BOARD & CARE HOME
FACILITY NUMBER: 486803302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80078(a)
80078(a) RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION

The licensee shall provide care and supervision as necessary to meet the client's needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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**Based on LPA observation and record review licensee failed to ensure that there was sufficient
staff on duty at all times necessary to meet the needs of clients in care which presents an immediate health and safety risk to clients in care. S1 was discovered to have left the facility with 3 clients in the home without any care or supervision.
POC Due Date: 09/21/2023
Plan of Correction
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Licensee is to ensure that there is sufficient staff to supervise clients in care and ensure health and safety of the clients. Licensee to submit an updated LIC500 and update facility's policy and procedures regarding personnel practices and ensure clients are not left unattended and submit to CCL by 9/21/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/14/2023 05:48 PM - It Cannot Be Edited


Created By: Carol Fowler On 09/14/2023 at 05:27 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: WILLIAMS BOARD & CARE HOME
FACILITY NUMBER: 486803302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health Related Services. Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation **LPA observed medication on kitchen table, Tylenol in clients room located in dresser and a unlocked medication cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Licensee/Administrator to ensure all medications are locked and inaccessible to clients. Licensee to provide all staff medication training in accordance with regulation and to submit proof of training to include trainer, attendees, date of training and topics covered by 9/20/2023. All medications were locked at the time of inspection.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023


LIC809 (FAS) - (06/04)
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