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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803662
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:21:31 AM

Document Has Been Signed on 10/21/2022 11:21 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:PEACH HUB, THEFACILITY NUMBER:
486803662
ADMINISTRATOR:GARCIA, JIM BERNARD PFACILITY TYPE:
775
ADDRESS:380 PITTMAN ROADTELEPHONE:
(707) 389-2403
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 45CENSUS: 16DATE:
10/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Program Manager, Jeremy CondezTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Peach Hub, The for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO) on October 3, 2022. LPA was greeted at the door by Program Manager, Jeremy Condez, and was granted access into the facility.

CCL received an incident report reporting a medication error. The error occurred on September 29, 2022 due to a miscommunication. Staff was preoccupied with another client and did not realize it was time for C1's medication (See LIC 809D). Responsible party and prescribing physician were notified of the medication error. LPA obtained copies of the Medication Assessment Record (MAR) for the month of September for C1 that reflects the said medication error.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights was given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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Document Has Been Signed on 10/21/2022 11:21 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/21/2022 at 07:09 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: PEACH HUB, THE
FACILITY NUMBER: 486803662

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B)-Health Related Services:
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff
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Licensee shall retrain ALL staff regarding medication passes and documentation as part of the Plan of Correction. In addition, Licensee shall provide LPA a written summary on how future compliance will be met.
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designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
(B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:

Based off an incident report that was forwarded to the Regional Office (RO) on October 3, 2022, C1 was not administered the medication timely during medication passes which poses an immediate Health, Safety and Personal Rights risk to the client(s) in care.
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Administrator requested a Plan of Correction (POC) extension for October 26, 2022. POC extension granted.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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