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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803637
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:32:19 PM

Document Has Been Signed on 09/06/2024 01:32 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:ROSEWOOD CRISIS RESIDENTIALFACILITY NUMBER:
486803637
ADMINISTRATOR/
DIRECTOR:		LEESA DURST-WIESMANFACILITY TYPE:
772
ADDRESS:508 ALABAMA STREETTELEPHONE:
(510) 415-4672
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 16CENSUS: 7DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Leesa Durst-Wiesman (Administrator)TIME VISIT/
INSPECTION COMPLETED:
01:47 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required 1 Year Inspection. This facility operates as a Social Rehabilitation Facility for persons with Mental Disabilities. LPA met with Leesa Durst-Weisman Administrator. Required postings were observed.

LPA/Administrator toured the buildings and grounds and observed the following: The facility was at comfortable temperature and exits free from obstructions. Bedrooms were furnished per regulation, hygiene and linen supplies were available. Hot water temperature measured between 105.4, 115.2, and 111.4 degrees F, which is within regulation of 105 to 120 degrees F. Fire extinguishers were charged and serviced March 2024. The facility has a hard wired sprinkler system; smoke and carbon monoxide detectors were available and functional throughout the facility. The last disaster drill was conducted on 9/5/2024. The facility does not have an evacuation chair yet. They just placed an order to get one (technical violation issued). The facility have at least two days of perishable and one week of nonperishable food supply, properly stored and handled per regulation. Medications centrally stored and locked in the medicine room. Medication and medication records were reviewed. Activity schedule and menus were observed. Facility do not handle cash resources.

LPA initiated file review at 9:15am. Seven client's files and five staff files were reviewed. Three out of seven clients do not have a medical assessment on file. All clients have their care plans updated. Staff have current CPR/1st aid and additional required training hours completed. However, one out of five staff (S1) do not have a health screening on file. Per Administrator, previous staff in charge of maintaining staff files updated did not obtain one for S1, but they will send S1 to have one done as soon as possible (technical violation issued). Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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: ROSEWOOD CRISIS RESIDENTIAL
FACILITY NUMBER: 486803637
VISIT DATE: 09/06/2024
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Continues from LIC809...

During today's visit, LPA followed up on an incident report submitted on 8/29/24 involving client (C1) who on 8/28/24 arrived from Sutter Center at 11am. C1 completed their intake assessment with staff, approximate an hour later an outside person who currently have a restraining order against client arrived and brought cash for C1. C1 was observed by staff running out of the back gate and was pursued by staff where C1 obtained illegal substances, smoked, attempted to run back into the facility bringing the illegal substances with them, but staff was able to prevent this from happening. At approximate 2pm another client informed staff that they observed C1 running out of the gate, then staff follow them and observed them completing a drug transaction outside. Staff requested C1 to hand over the packet obtained and they replied that the area where the facility is located is triggering their behavior due to there is a drug dealer on every corner. Staff have contacted C1's responsible party to address the issue of person who has a restraining order bringing cash to C1. The facility staff have destroyed the substances obtained by C1 and provided staff training. LPA have a discussion with administrator about the importance of updating C1's care plan due to these incidents above mentioned, because the initial assessment did not address them. Administrator agreed to conduct an updated appraisal with C1.

Administrator agreed to submit updates of the following documents by 9/20/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E if there are any changes) and control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2024 01:32 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/06/2024 at 12:08 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: ROSEWOOD CRISIS RESIDENTIAL
FACILITY NUMBER: 486803637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(a)
Client Medical Assessments
(a) Prior to admitting a client into care or within 72 hours of admission, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in three out of seven clients do not have a current medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Asdministrator agreed to obtain client's medical assessment timely and will submit a self-certification form (LIC9098) to CCL notifying the DEpartment that they have corrected the deficiency by not later than SEptember 20, 2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
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