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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803775
Report Date: 05/15/2024
Date Signed: 05/15/2024 01:51:24 PM

Document Has Been Signed on 05/15/2024 01:51 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:ISABELLA'S HOMEFACILITY NUMBER:
486803775
ADMINISTRATOR/
DIRECTOR:		SELENE CRUZ-ASTORGAFACILITY TYPE:
737
ADDRESS:915 GOLD COAST CTTELEPHONE:
7077593784
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Angelica (Angie) Gonzalodo, Caregiver/House Manager & Selene Cruz-Astorga, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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At approximately 10:10 AM Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident visit. LPA was greeted by staff, temperature screened before entry into the facility, and logged in to the Visitor's Log. LPA met with Angelica (Angie) Gonzalodo, Caregiver/House Manager, and informed her the purpose of today's visit was to investigate a medication error with C1 as reported via an incident report from 5/5/2024 at 3:00 PM and received by CCLD on 5/7/2024. LPA requested copies of S1's current training records, the current staffing schedule and roster, and to review the medication administration record (MAR) for C1. Licensee/Administrator, Selene Cruz-Astorga arrived shortly after and provided requested documentation including a copy of the mitigation meeting and coaching digitally signed by S1 following the incident.

At approximately 10:40 AM, LPA initiated tour of the facility with House Manager and was informed there are currently 4 clients in care, all of whom were home at the time of the visit. LPA was informed that only one client, C2, regularly attends day program. However, C2 chose to remain home today, in order to go to the DMV to apply for a new identification, as C2 has gone through the process of a legal name change.

LPA observed the facility was clean and orderly. Facility was a comfortable temperature of 70 F. Clients' rooms had all the required furnishings and LPA observed a supply of clean linens and blankets available to clients. Chemical and toxins were secured and not accessible to residents. However, LPA observed over the counter medications present in an unlocked staff cabinet in the unlocked garage which is accessed through the laundry room which was unlocked. House Manager removed the items immediately and locked them up. LPA requested Licensee/Administrator submit a statement regarding the requirement that all medications be inaccessible to clients in care, which shall be signed by all staff acknowledging their understanding. LPA advised Licensee/Administrator to lock the medications with the centrally stored medications.

(Continued on 809-C)
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ISABELLA'S HOME
FACILITY NUMBER: 486803775
VISIT DATE: 05/15/2024
NARRATIVE
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Continued from LIC809

Each room has a locking cupboard for storing toxins and soaps, making them inaccessible to clients in care. LPA observed the living room, family room, dinning room and kitchen areas to be clean and orderly with all cabinets with contents which could pose a risk of harm to clients in care locked and secure. There were four (4) additional care staff present at the time of inspection. Staffing was adequate to care for and conduct activities with clients at the time of inspection. LPA observed 3 of 4 clients spending time in the shaded back yard, playing checkers and listening to music.

At approximately 11:30 AM, LPA reviewed S1 and C1 files, which were complete and up to date. LPA also confirmed all staff present at the facility were fingerprinted and associated.

During this inspection, LPA followed up on an incident report which involved a medication error referenced above. According to the IR and interviews with both House Manager and Licensee/Administrator, the morning staff (S1) administered C1's 6:30 AM medication not realizing the morning dose had already been given by the NOC shift (S2), prior to change of shift. At 3:00 PM evening staff (S3) noticed to error and contacted C1s physician immediately. S3 was informed by the client's physician that it wasn't much of a difference for C1's treatment and asked S3 to skip C1's next dose. According to the IR and interviews with both House Manager and licensee/Administrator, staff monitored C1 and reported no physical or behavioral changes with C1 throughout the day. Additionally, House Manager and Licensee/Administrator informed LPA the S1 was likely rushing to give morning medications to then begin the morning routine and didn't pay attention that the medication had already been given by the NOC shift. licensee/Administrator informed LPA that she discussed the medication error with S1 and provided LPA a copy of the mitigation plan signed by both Licensee/Administrator and S1. LPA was informed by Licensee/Administrator that S1 normally gives this AM dose. LPA was informed that S2 had not yet been coached regarding the incident. LPA requested that S2 receive coaching on conducting a change of shift hand-off report with the on-coming shift prior to ending their shift especially when anything out of the normal routine or behavior patterns occurs, such as administering a medication that is normally given by the AM shift. Licensee/Administrator agreed to provide proof of coaching with S2 to CCL by the attached requested due date. LPA reviewed S1 and S2's files and observed both have completed DSP training.



Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview was conducted with Licensee/Administrator. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2024 01:51 PM - It Cannot Be Edited


Created By: Julie Florio On 05/15/2024 at 01:22 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: ISABELLA'S HOME
FACILITY NUMBER: 486803775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ...
(4)The licensee shall assist residents with self-administered medications as needed.
This requirement was not as evidenced by:
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Licensee/Administrator to submit proof of coaching S1 regarding how to prevent medication errors in the future.

Licensee agrees to submit proof of coaching S2 on conducting a change of shift hand-off report with the on-coming
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Based on record review, the licensee did not comply with the section cited above by not ensuring that the medications were given as prescribed.
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shift prior to ending their shift, especially when anything out of the normal routine or behavior patterns occurs, such as administering a mediction that is normally given by the AM shift. Documentation to be provided to LPA by POC due date of 5/16/2024.

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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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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