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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803302
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:10:57 PM

Document Has Been Signed on 09/24/2024 01:10 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:WILLIAMS BOARD & CARE HOMEFACILITY NUMBER:
486803302
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, KATRINAFACILITY TYPE:
735
ADDRESS:430 FORDHAM DRIVETELEPHONE:
(707) 652-2445
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Katrina Williams (Administrator)TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with house manager, Margaret Henley. Administrator Katrina Williams arrived later. Annual fees are current. Contact information was reviewed. Required postings were observed.

LPA/staff initiated a tour of the facility at 9:30 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. During visit, LPA/house manager observed garbage in the garage containing soda cans attracting insects and flies. Per house manager, clients do collect them for recycling purposes (technical advisory was issued). Clients rooms furnished per regulation. Bathrooms have required grab bars and mats. Water temperature in client's bathroom measured at 98.4 degrees F which are not 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. Medications were centrally stored and locked. Fire extinguisher was last inspected September, 2024. Smoke Detectors and Carbon Monoxide Detector were tested and operational during inspection. House manager was unable to provide documentation that a disaster drill was conducted within the last quarter. The facility does not handle their cash resources. During LPA's visit, the clients were observed at home. LPA inquired if they go to day programs/wellness centers and house manager stated that they don't want to participate in activities. LPA asked house manager for their activity calendar, but staff replied that they don't have one. Clients' physician report indicated that they are allowed to go out unassisted, so they do go out on their own. LPA/administrator discussed the importance to meet this requirement as stated per regulation and have requested them to perform an assessment of client's preferences, develop one activity calendar and follow it as stated per regulation (technical advisory issued). Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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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: WILLIAMS BOARD & CARE HOME
FACILITY NUMBER: 486803302
VISIT DATE: 09/24/2024
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Continues from LIC809...

At approximate 9:45am LPA/staff observed the refrigerator has locks that were unlocked during the visit. Per staff, they lock the fridge at night to prevent clients from having access to food because, clients continue to go through the refrigerator, so they put locks on them. LPA observed a bowl of oranges and four trays of pastries on table. During file review, LPA noticed that there is no waiver on file and there are previous CCL reports addressing the same issue without any documentation received by the Department as of today (technical violation issued). LPA discussed with staff that a waiver request needs to be submitted to the Department for review and approval if they wish to have a locked fridge, outlining why the refrigerator needs to be locked and how adequate and readily available snacks and beverages will be provided to clients. The house manager agreed to submit a waiver request and its supporting documents to the Department by not later than 9/27/24.

LPA initiated file review of two staff files and six client files. One out of six clients do not have a physician report on file. One out of six clients (C2) do not have a medical assessment on file (technical violation was issued). Staff have required First Aid Certificates and required training hours. Administrator Certificate for Administrator, Katrina Williams 7008814735 expired on 6/20/2024. LPA reviewed the Department's pending/active administrator certification list and found their name as of 8/7/24 is pending review.

Administrator agreed to submit updated copies of the following to CCL by 9/27/2024: (LIC 500) Personnel Report, (LIC 610D if there are any changes) Emergency Disaster Plan, (LIC 308) Designation of Responsibility and control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation, see LIC809D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Administrator Katrina Williams was available over the phone, LPA discussed with administrator deficiencies found, conduced exit interview with them and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2024 01:10 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/24/2024 at 12:55 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: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's staff observation, the licensee did not comply with the section cited above in one out of one bathroom water measured 98.4 F degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator agreed to submit LIC9098 self-certification form that water temperature was adjusted per regulation by POC due date to clear citation.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in by not conducting a disaster drill within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator agreed to submit LIC9098 self-certification form that disaster drill was conducted per regulation by POC due date to clear citation.
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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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