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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803541
Report Date: 02/28/2022
Date Signed: 02/28/2022 11:50:47 AM

Document Has Been Signed on 02/28/2022 11:50 AM - 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:PEOPLE'S CARE ROLLING HILLSFACILITY NUMBER:
486803541
ADMINISTRATOR:RAY, MORGANFACILITY TYPE:
735
ADDRESS:4219 ROLLING HILLS LNTELEPHONE:
(951) 255-1727
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff Member, Marycruz GuidoTIME COMPLETED:
12:00 PM
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At approximately 10:30AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct an Annual inspection visit and was greeted by Staff, Marycruz Guidl. The inspection is focused on the Infection Control procedures and practices of this facility. The Administrator, Morgan Ray, was not available for today's visit but was available via telephone. Administrator has given permission for staff member to sign.

Upon arrival at the facility, LPAs had their temperatures checked and logged. LPAs conducted a walk-through of the facility and observed the following: Handwashing signs were observed in the bathrooms and at sinks. Per Administrator, the facility received new COVID signs and they will be put up. Observed staff were wearing masks. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

All staff have received training on infection control. Staff have not been N95 fit-tested but LPAs discussed with Administrator who indicated they were actively working on it. Facility has a cleaning and disinfecting schedule that occurs twice per shift. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders.

Continued on LIC-809C.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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: PEOPLE'S CARE ROLLING HILLS
FACILITY NUMBER: 486803541
VISIT DATE: 02/28/2022
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Continued from LIC809.

LPAs observed that the facility washing machine had an out of order sign. Per conversation with staff member, the washing machine has been not working for about two weeks but a new one is being delivered on March 2, 2022. Currently, laundry is being done at People's Care Morning Sun.

Fire Extinguisher was last serviced March 2021. Per Administrator, carbon monoxide detectors were out of battery so were taken down 2/27/2022 to replace them. Detectors will be put back up by the PM shift lead. LPAs discussed with staff that the batteries need to be replaced immediately and there should not be a delay between taking them down and changing the battery.

LPAs also followed up on a special incident report for a medication error.

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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2022 11:50 AM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/28/2022 at 11:21 AM
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: PEOPLE'S CARE ROLLING HILLS
FACILITY NUMBER: 486803541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of incident report, 1 of 4 clients did not receive their medication as prescribed. This poses an immediate health and safety risk to clients in care.
POC Due Date: 03/01/2022
Plan of Correction
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Administrator will send proof of medication re-training for Staff 1 by POC date, Tuesday, March 2, 2022.
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:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
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