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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803525
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:02:10 PM

Document Has Been Signed on 08/31/2023 04:02 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:DARWIN FACILITYFACILITY NUMBER:
486803525
ADMINISTRATOR:HALL, MYRTLEFACILITY TYPE:
735
ADDRESS:1612 TUCSON CIRCLETELEPHONE:
(707) 426-4981
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 2DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Joanna Hall, Lead StaffTIME COMPLETED:
04:15 PM
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On 8/31/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Joanna Hall. The facility currently provides care for 2 clients, all of which were attending day program at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/9/2023. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food stored in the garage. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. LPA observed several canned good items that were past expiration date in 2022. LPA requested facility to review dry food supply and remove any items that are past expiration dates. There was a supply of linens, hygiene products and paper products available for clients located in the hallway.

Upon inspection of client bedrooms LPA observed client (C1) to have a live bedbug on C1's bedroom wall. LPA also observed dead bedbug shells under C1's bed. The facility had recently contracted with pest control to resolve the infestation however, signs of live bedbugs were observed during inspection. LPA also observed a second live bedbug on the wall panelling between clients' (C1 & C2) bedrooms (photos taken). LPA continued to complete the report from outside of the facility due to bedbug concerns. LPA requested for Lead staff to provide proof of 1st aid & CPR training. Upon review LPA found 1 out of 2 staff without current CPR & 1st Aid certification completed.

Due to unexpected circumstances within the facility and potential safety risk to LPA; physical tour of the facility was completed but will require an annual continuation for full medication, P&I and facility, staff and client file review.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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: DARWIN FACILITY
FACILITY NUMBER: 486803525
VISIT DATE: 08/31/2023
NARRATIVE
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Licensee, Myrtle Hall's Administrator Certification 6022508735 is currently active until 12/3/2024.

LPA requested the following documents be sent to CCL by COB 9/14/2022:
- Proof of Ownership or lease/rental agreement


Civil Penalty is also being assessed in the amount of $250.00 due to 1 repeat citation issued for the same section in less than 12 months. Today's assessment of $250.00 is for Title 22 Regulation # 80087(a) previously cited on 1/19/2023.

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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 08/31/2023 04:02 PM - It Cannot Be Edited


Created By: Dominic Tobola On 08/31/2023 at 02:57 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: DARWIN FACILITY
FACILITY NUMBER: 486803525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above. LPA observed several dried good/canned food items that are past expiration date which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee agrees to review food supply and immediately remove any items that are spoiled or expired. Licensee to submit LIC9098 Proof of Corrections form to CCLD by POC date 9/1/2023, indicating that the item has been corrected.
Type A
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed multiple live bedbugs and dead bedbug shells located in client C1's bedroom and in between clients' (C1 & C2) bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee agrees to immediately contact pest control services and develop a plan of action to remove bedbugs from the facility. Facility to provide written plan of action to CCLD regarding pest control services by POC date 9/1/2023. Facility also agrees to write a plan of action on how staff will continuously monitor clients and client bedrooms for live and/or remnant bedbugs by 9/1/2023. Civil Penalty is also being assessed in the amount of $250.00 due to 1 repeat citation issued for the same section in less than 12 months. Today's assessment of $250.00 is for Title 22 Regulation # 80087(a) previously cited on 1/19/2023.
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:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/31/2023 04:02 PM - It Cannot Be Edited


Created By: Dominic Tobola On 08/31/2023 at 03:10 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: DARWIN FACILITY
FACILITY NUMBER: 486803525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff (S1) without current 1st Aid & CPR certification completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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Licensee agrees to complete required 1st Aid & CPR training for staff (S1). Proof of completed training to be submitted to CCLD by POC date 9/28/2023.
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:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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