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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803713
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:29:26 PM

Document Has Been Signed on 03/29/2022 01:29 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:RUTHIE'S HOMEFACILITY NUMBER:
486803713
ADMINISTRATOR:ROBIN BRANDONFACILITY TYPE:
735
ADDRESS:3789 CLAY BANK RDTELEPHONE:
(707) 673-2047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 2DATE:
03/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:House Manager Raquel CistacTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Canela arrived to deliver findings on complaint # 21-AS-20220310163110 at Ruthie's Home on 03/29/2022. LPA met with House Manager Raquel Cistac. During the complaint investigation, LPA toured the facility and observed deficiencies.

Upon arrival, LPA observed Staff (S1 & S2) without a face mask on while supervising clients in care. Licensee was previously warned via email on 01/13/2022 regarding the requirement of staff wearing a face mask in the facility. Additionally, record review, observations and statements received revealed Licensee/Administrator has not been available/working on the facility premises.
Administrator previously stated personal reasons for not being at the facility and designated Raquel Cistac as House Manager. LPA did not observe documentation of days Administrator worked at the facility (photos taken). LPA had requested documents needed to change the administrator from Robin Brandon to Raquel Cistac but as of today's inspection LPA has not received the documents.

Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Licensee Raquel Cistac whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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 03/29/2022 01:29 PM - It Cannot Be Edited


Created By: Karina Canela On 03/29/2022 at 10:17 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: RUTHIE'S HOME
FACILITY NUMBER: 486803713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
80072(a)(2)

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80072 Personal Rights: (a) ...each client shall have personal rights which include, but are not limited to, the following: (2)To be accorded safe, healthful ... to meet his/her needs.This Requirement was not met as evidenced by:
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Licensee to review CCL PINs regarding current COVID requirements. Licensee to submit a statement that they understand the requirements and staff shall comply to ensure the health, safety, and personal rights of the clients.
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Based on staff failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that S1&S2 failed to wear face covering while providing care and supervision to clients in care ...
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(continued) ...which is in violation of official government orders requiring the wearing of face coverings while working under specified conditions and facility is not following their mitigation plan to screen visitors (except for temp check) and have them sign in. This is a potential personal rights, health & safety risk to clients in care
Type B
04/05/2022
Section Cited
CCR85064(e)

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85064 Adminstrator Qualifications and Duties(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.This Requirement was not met as evidenced by:
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Licensee/Administrator to submit a written statement that they understand the regulation and include a plan of how they will meet the regulation, & provide an updated LIC500 indicating the hours and days they are present at Ruthie's Home. Licensee to submit to CCL by POC due date 04/05/2022
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Based on observation, interviews, and records reviewed, Licensee/Administrator did not ensure they were on the facility premises the minimum hours (20%) required as Administrator. This is a potential personal rights risk to clients in care.
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In addition, Licensee to submit documentation (LIC215, LIC500, LIC308, LIC501, & Administrator Certificate) that were previously requested for a change of Administrator
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:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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