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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803677
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:59:19 PM

Document Has Been Signed on 08/15/2023 01:59 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A RESIDENCEFACILITY NUMBER:
486803677
ADMINISTRATOR:ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:2264 CAMBRIDGE DRIVETELEPHONE:
(707) 631-3655
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 4DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Higinia Alvis, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an Annual Required 1 Year inspection and met with Administrator Higinia Alvis, Caregiver Alejandra Arciga was present during inspection.

Facility has a fire clearance for five (5) ambulatory clients. All seven (7) smoke alarms were working properly when checked during the inspection; The facility has 2 carbon monoxide detector which were working properly during inspection. Fire extinguisher, was tagged as required expiration date 05/12/2023. All exits were clear and unobstructed.

LPA toured the facility with Administrator. The hot water was checked and within regulations. LPA observed a sufficient supply of food. LPA observed a sufficient supply of cleaners, hygiene products, and paper products. Resident medications are locked up in a cabinet making them inaccessible to clients in care. LPA observed a sufficient supply of linen for client use. The facility has sufficient furnishings for clients use.

During the tour LPA observed the following deficiencies:
  • Two bedrooms in the garage that are not on the facility sketch.
  • Staff (S2) is not associated to the facility.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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Document Has Been Signed on 08/15/2023 01:59 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/15/2023 at 12:38 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: A RESIDENCE
FACILITY NUMBER: 486803677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)(A)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.

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 having a 2 bedrooms created in the garage area that has not been fire cleared or on the facility sketch, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/22/2023
Plan of Correction
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Administrator will submit an LIC200 and new facility sketch to CCL no later than the POC date.
Type B
Section Cited
CCR
87355(e)(4)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today’s visit and review of records with Administrator, staff S2 fingerprint cleared and S2 is associated to another facility. The licensee did not comply with the section cited above by having working at the facility and S2 is not associated, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/22/2023
Plan of Correction
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Administrator will fax or mail completed forms to CCL, in addition Facility to send in written plan on how they will ensure they meet regulation to department by POC date.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A RESIDENCE
FACILITY NUMBER: 486803677
VISIT DATE: 08/15/2023
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Continue from LIC809

The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be orderly during the visit. The LPA observed that clients rooms, common areas, hallways, and bathrooms had sufficient lighting for clients in care.

LPA is requesting the following forms be updated and submitted to CCL by 8/22/23:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond in Required Amount
· Infection Control Plan If updated


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.

Exit interview conducted and copy of report and appeal rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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