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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803713
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:23:55 PM

Document Has Been Signed on 12/09/2024 04:23 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:RUTHIE'S HOMEFACILITY NUMBER:
486803713
ADMINISTRATOR/
DIRECTOR:		ROBIN BRANDONFACILITY TYPE:
735
ADDRESS:3789 CLAY BANK RDTELEPHONE:
(707) 673-2047
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Raquel Cistac, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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At approximately 10:15 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and was greeted by Staff 1 (S1). Raquel Cistac, Designated Responsible Party (DRP) was contacted and arrived at approximately 11:15 AM. Facility is an Adult Residential Facility with three (3) ambulatory clients in care -- 2 were away at Day Program and 1 was present during today's visit. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 11:20 AM, LPAs initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have all of the appropriate furnishings as outlined in Title 22 regulations. However, LPA's observed 3 dresser drawers missing knobs and 1 broken dresser drawer in Client 2 (C2's) bedroom and 1 briken dresser drawer in Client 1 (C1's) bedroom, (see LIC809D). Cabinets containing cleaning supplies and other items that could pose a risk were locked. However, LPA's observed a magnet to unlock the kitchen sink cabinet stored out in the open next to cabinet and inaccessible to clients in care, (see LIC809D). Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. However, LPA's observed over 8 instances of expired food, (see LIC809D). Medications were centrally stored and locked. There is space in the backyard for activities. LPAs observed games and activites available for clients. LPAs observed an internet access device available to clients in care. Facility has internet available and the phone was tested an operational during today's inspection.

Facility's fire extinguishers were observed charged and were last serviced May 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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: RUTHIE'S HOME
FACILITY NUMBER: 486803713
VISIT DATE: 12/09/2024
NARRATIVE
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Continued from LIC809...

Facility conducts semi-annual disaster drills, and the most recent drill was conducted August 2024. However, DRP was unable to provide proof of any training completed, (see LIC809D). LPAs advised DRP that drills shall be completed on a quarterly basis. LPAs observed facility's infection control plan and emergency disaster plan which was last updated June 2024. LPAs observed a supply of PPE, emergency supplies, first aid kits, and flashlights for emergency preparedness. DRP states the facility does not have a backup generator.

At approximately 12:00 PM, LPAs reviewed 3 staff files and 3 client files. S1 has a health screening that has not been signed and dated by a physician, and Staff 3 (S3) is missing a signed and dated personnel report, (see LIC809D). 3 of 3 staff files reviewed have all of the remaining required paperwork and proof of current First Aid training. Both C1 and C2 are missing their Needs and Services Plan, C1 is missing a consent for emergency medical treatment, and C2 is missing signed and dated admissions agreement, (See LIC809D). Three (3) of three (3) client files reviewed have all the remaining required paperwork. Staff coordinate medical and dental visits for the clients and take them to their appointments.

At approximately 1:50 PM, LPAs reviewed medications and medication records which are maintained and stored in compliance with regulation. However, LPAs noted that C2 had 1 new medication which had not yet been recorded onto their centrally stored medication record. LPAs advised DRP to ensure all medications are immediately recorded upon receipt to remain in compliance. LPA reviewed P&I monies and logs, which were organized and maintained and stored in accordance with regulation.

Required Change of Administrator Documents Shall be Submitted to CCL within 30 days of this visit:

  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate

Continued on LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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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: RUTHIE'S HOME
FACILITY NUMBER: 486803713
VISIT DATE: 12/09/2024
NARRATIVE
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Continued from LIC809C...
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired
  • Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • Bond (updated)
  • Affidavit Regarding Client Cash Resources (updated)
  • LIC610D Emergency Disaster Plan (updated)
  • LIC9020 Client Roster


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 DRP and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 12/09/2024 04:23 PM - It Cannot Be Edited


Created By: Julie Florio On 12/09/2024 at 03:32 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: RUTHIE'S HOME
FACILITY NUMBER: 486803713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in ensuring that all toxins and cleaning solutions were inaccessible to client in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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DRP to submit self-certfication to CCL stating they will ensure all toxins and items which could pose a risk to clients in care are made inaccessible at all times by POC due date 12/10/2024.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 12/09/2024 04:23 PM - It Cannot Be Edited


Created By: Julie Florio On 12/09/2024 at 03:32 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: RUTHIE'S HOME
FACILITY NUMBER: 486803713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in ensuring that client dresser drawers are maintained in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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DRP to submit picture proof that all 5 dresser drawers have been repaired bringing the facility back into compliance to CCL by POC due date 12/27/2024.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring that all personnel records are complete, signed and dated, and in compliance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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DRP to submit an updated health screening signed and dated by a physician for S1 and a signed and dated personnel report for S3 to CCL by POC due date 1/10/2025.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 12/09/2024 04:23 PM - It Cannot Be Edited


Created By: Julie Florio On 12/09/2024 at 03:32 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: RUTHIE'S HOME
FACILITY NUMBER: 486803713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 in more than 8 instances of observed expired food, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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DRP to submit self certification that all food in the facility has been inspected, is fit for human consumption and all expired food has been discarded to CCL by POC due date 12/27/2024.
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that all client files are complete, signed and dated, and in compliance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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DRP to submit an updated, signed, and dated Needs and Services Plan for C1 and C2, a Consent for Emergency Treatment for C1, and a signed and dated Admissions Agreement for C2 to CCL by POC due date 1/10/2025.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 12/09/2024 04:23 PM - It Cannot Be Edited


Created By: Julie Florio On 12/09/2024 at 03:32 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: RUTHIE'S HOME
FACILITY NUMBER: 486803713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that facility has documented emergency drills available for inspection upon request by licensing personnel, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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DRP to submit proof of current emergency disaster drill conducted to CCL by POC dues date 12/16/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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