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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803677
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:31:01 PM

Document Has Been Signed on 08/16/2024 03:31 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/
DIRECTOR:		ALVIS, HIGINIAFACILITY TYPE:
735
ADDRESS:2264 CAMBRIDGE DRIVETELEPHONE:
(707) 631-3655
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 5CENSUS: 3DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Higinia Alvis, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 8:55 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by DSP (S1). Higinia Alvis, Licensee/Administrator was contacted and arrived at approximately 10:40 AM. Facility is an Adult Residential Facility with three (3) Ambulatory Developmentally Disabled Clients in care, all of whom were away at Day Program. Licensee is venderized with North Bay Regional Center (NBRC) for level 3 clients.

At approximately 9:10 AM, LPA initiated a tour of the facility with S1 and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens available to clients. However, LPA observed no paper towels available in facility bathrooms for clients. LPA observed hand towels in the bathrooms and informed S1 and Licensee that to be in compliance, hand towels are not permitted. Licensee removed them immediately and placed paper towels in the bathrooms. Clients' bedrooms were inspected and observed to have all of the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. However, LPA observed facility door to laundry, storage, and staff bedrooms open throughout the duration of todays inspection making detergents, bleach, cleaning supplies, and other toxins accessible to clients in care. LPA advised S1 and Licensee to ensure all chemicals and toxins are stored and inaccessible to clients in care. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPA observed expired, freezer burned, and uncovered food stored in the facility refrigerator and freezers, as well as opened food not labeled with open/expiration dates on packages and containers. LPA discussed compliant food storage with Licensee who conveyed understanding and agreed to bring facility into compliance. Medications were centrally stored and locked. However, LPA observed S1 go to the laundry area and return with client medication bottles, which they then locked in the centrally stored medication cabinet in the facility main living area.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A RESIDENCE
FACILITY NUMBER: 486803677
VISIT DATE: 08/16/2024
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Continued from LIC809...

LPA discussed compliant medication practices with S1 and Licensee. Both conveyed understanding and agreed to bring facility into compliance.

LPA observed a supply of games and craft supplies for clients and was informed that facility staff and/or Licensee take clients on weekend outings of their choice and usually plan a yearly vacation. Facility has internet available to clients in care and the phone was tested and operable. Licensee states that each client has their own internet access device. There is a shaded patio and seating area in the backyard with outdoor space for activities. There is also a 10'x12' structure which is noted on the facility sketch which appeared to be occupied and partially used as living quarters and the remainder used for storage. Licensee had staff immediately unmake and disassemble the bed, agreed to pack up the observed personal items and assured LPA the structure will solely be used for storage and tools moving forward.

Facility's fire extinguishers was observed charged and was last serviced May 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted August 2024. LPA observed facility's emergency disaster plan which was last updated January 2023 and the register facility clients was last updated January 2024. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid kit. Administrator states the facility does not have a backup generator.

At approximately 12:00 PM, LPA reviewed three (3) staff files and three (3) client files. Three (3) of three (3) staff files reviewed have the required First Aid certificates. Each has current CPR certification as well. LPA observed that three (3) of three (3) staff files have all the required paperwork. Facility had the required paperwork for three (3) of three (3) clients. LPA advised Licensee to ensure all required documentation is signed and dated in client files for review upon request. Licensee coordinates medical and dental visits for the clients and takes them to their appointments.

At approximately 1:30 PM, LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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: 08/16/2024
NARRATIVE
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continued from LIC809C...

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC610D - Emergency Disaster Plan
LIC500 - Personnel Report

Deficiencies cited during today's inspection. (See LIC809D).

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.

Exit interview conducted with Licensee and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/16/2024 03:31 PM - It Cannot Be Edited


Created By: Julie Florio On 08/16/2024 at 02:47 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: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in ensuring all disinfectants, cleaning solutions, and poisons which could pose a danger if readily available to clients were stored where inaccessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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4
Licensee agrees to submit photo proof that all disinfectants, cleaning solutions, and poisons which could pose a danger if readily available to clients are stored where inaccessible to clients to CCL by POC due date 8/19/2024.
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in ensuring all food is checked for expiration dates, stored safely and labeled after opening, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee to submit photo proof that all food has been checked and all staff have been coached on proper labeling and food storage to CCL by POC due date 8/19/2024
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 08/16/2024 03:31 PM - It Cannot Be Edited


Created By: Julie Florio On 08/16/2024 at 02:47 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: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in ensuring medications are not made accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee to submit phot proof and a written statement that all staff have been coached on compliant medication storage and administration practices to CCL by POC due date 8/19/2024.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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