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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803740
Report Date: 05/07/2024
Date Signed: 06/10/2024 09:39:16 AM

Document Has Been Signed on 06/10/2024 09:39 AM - 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:KALUSUGAN HOMES - BOXWOODFACILITY NUMBER:
486803740
ADMINISTRATOR/
DIRECTOR:		LEWIS-BARRETO, ANNABELLEFACILITY TYPE:
735
ADDRESS:2592 BOXWOOD LANETELEPHONE:
(707) 439-1816
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Annabelle Lewis-Barreto, Administrator/Licensee & Ruben Poblete, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Direct Support Professional (DSP) Ian Rose Devera. Licensee, Annabelle Lewis-Barreto and Administrator, Ruben Poblete were contacted via phone by DSP and arrived about 20 minutes later. Facility is an Adult Residential Facility with Developmentally Disabled Clients in care. LPA observed 1 of 4 clients home and was informed that 3 out of 4 clients were away at day program. LPA was informed that client at home is a newer resident who currently has a suprapubic permanent catheter which has made placing her in a day program challenging. LPA informed that the client is on a waiting list at a few day programs presently, has a restrictive health condition care plan signed by a physician and has a home health nurse who manages the care and maintenance of this client's catheter.

At approximately 9:20AM, LPA initiated a tour of the facility and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in clients' bathrooms measured 109.9 and 108.3 degrees F, which is within allowable range of 105 to 120 degrees F per regulation. LPA observed facility has all required signage, but it is posted in the facility's laundry room. LPA advised Licensee and Administrator to move signage into a conspicuous place at the front entrance of the facility. LPA observed a supply of clean linens available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations.Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods and a supply of bottled water. Medications were centrally stored and locked. There is outdoor space for clients and the grounds are safe, clean and orderly. LPA observed a locked shed in the backyard which is used solely as an office by Licensee and Administrator. LPA also observed a locked trailer stored on the side of the house in the front yard, which is stored here at the facility by Licensee and Administrator but remains locked at all times and is for their personal use only.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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: KALUSUGAN HOMES - BOXWOOD
FACILITY NUMBER: 486803740
VISIT DATE: 05/07/2024
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Continued from LIC809

The facility is hardwired. Fire extinguisher is charged and was last serviced February 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Facility conducts monthly disaster drills on both day and evening shifts, and the most recent drill was conducted May 2024. LPA observed the facility's infection control plan, first aid kit, and emergency disaster plan which are all in compliance with regulation.

At approximately 9:55AM 5 staff files and 4 client files were reviewed. All staff have current required First Aid certificates, and all have current CPR as well. All staff have been background screened and cleared and are associated to the facility per regulation. All reviewed staff files contained the required documentation per regulation including health screenings and TB results. 5 of 5 staff files contained documentation of medication training.

LPA observed doctors orders for a seat belt and postural supports as well as a waiver from CCL for one client in care. LPA also observed doctors orders for food thickener for two clients. LPA observed medications centrally stored and locked. LPA reviewed medications and medication records which are maintained within regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

Exit interview conducted with Licensee whose signature on this document confirms receipt. No Deficiencies were cited. This report was reviewed with Licensee and Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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