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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803713
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:38:59 PM

Document Has Been Signed on 10/22/2021 03:38 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
10/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Raquel Cistac, House ManagerTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived to Ruthie's Home facility unannounced regarding a complaint investigation. Upon arrival, LPA observed Individual (I2) who was working with clients. A review of facility records and interviews conducted revealed individual (I2) was working at Ruthie's Home since 10/21/21 (photos taken) for a total of two days. LPA verified through the facility Guardian Personal Report/Roster and with Community Care Licensing Rohnert Park Regional Office that I2 has a fingerprint clearance but was not associated to Ruthie's Home facility as required.

LPA explained prior to anyone working (including shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation.
Licensee and House Manager stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at Ruthie's Home, the individual must obtain a fingerprint clearance and be associated to the facility.

A Civil penalty in the total amount of $200.00 was assessed today for individual (I2), who was not associated to this facility as required.

Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Raquel Cistac, House Manager, who's signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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 10/22/2021 03:38 PM - It Cannot Be Edited


Created By: Karina Canela On 10/22/2021 at 02:31 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: RUTHIE'S HOME
FACILITY NUMBER: 486803713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2021
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance - (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 80019(f). This requirement was not met as evidenced by:
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House Manager agreed to associate I2 by 10/22/2021 by close of business and verify association. I2 is required to be associated to the facility prior to returning to work.
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Based on record review, observations, and interviews conducted: Licensee did not request a transfer of a criminal record clearance for individual (I2) prior to working at the facility.
This is an immediate safety risk to the residents in care.
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Licensee to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 10/25/2021 to Community Care Licensing

**Civil Penalty assessed in the amount of $200.00

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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:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021


LIC809 (FAS) - (06/04)
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