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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803794
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:23:57 PM

Document Has Been Signed on 11/22/2024 03:23 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:CHICO'S HOMEFACILITY NUMBER:
486803794
ADMINISTRATOR/
DIRECTOR:		MORALES, CECILIAFACILITY TYPE:
735
ADDRESS:832 WORLEY RDTELEPHONE:
(707) 688-5075
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 3DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Cecilia Morales, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 12:55 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Cecilia Morales, Licensee/Administrator. Facility is an Adult Residential Facility with three (3) ambulatory clients in care, all of whom were away at Day Program. Facility is vendored with North Bay Regional Center (NBRC).

At approximately 1:10 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in 2 out of 3 clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. The third bathroom has a sensor operated sink which measured 90.6 degrees F. Licensee agreed to replace the faucet this weekend. LPA observed a supply of clean linens and paper, hygiene. and incontinent care products available for clients. 1 of 2 clients' bedrooms inspected was observed missing chairs and dressers, which Licensee states is due to client behaviors. LPA advised Licensee to ensure the clients' care plans are updated to reflect these behaviors with the facility's prevention measures and have them signed and dated by the clients' responsible parties. Cabinets containing cleaning supplies and other toxic chemicals were locked. LPA observed an unlocked drawer with a broken lock in the kitchen containing knives, scissors, and other sharp objects which pose a risk to clients in care, (see LIC809D). Licensee removed the items and stored them in a locked staff bedroom until they can repair the drawer lock. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPA observed 5 out 7 non-perishable food items expired. Licensee removed all the items immediately and had staff go through all the food to ensure there are no additional expired items in the facility. Medications were centrally stored and locked. There is outdoor space for activities in the back yard. LPA advised Licensee to display the required posters in a more conspicuous place within the facility and to obtain and post the CCLD reporting poster as required per regulation.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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: CHICO'S HOME
FACILITY NUMBER: 486803794
VISIT DATE: 11/22/2024
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Continued from LIC809...

Licensee states the clients each attend day programs M-F. Licensee states that when the clients are home, they enjoy trips to the park, eating out, TV, time on their electronic devices, and weekends/visits with their families. Facility has internet available to clients in care. LPA was informed the Licensee removed the facility telephone because they weren't using it, but Licensee states they still have telephone service and assured LPA they will bring the telephone back to the facility today to bring the facility back into compliance with regulation.

Facility's fire extinguisher was observed charged and was last serviced 11/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Licensee states the facility conducts bi-annual disaster drills, with the most recent drill conducted 9/2024. LPA advised Licensee to ensure documentation of all drills in available to licensing for inspection upon request. Additionally, LPA informed Licensee that disaster drill are now required on a quarterly basis. LPA observed facility's infection control plan and emergency disaster plan which was last updated 11/2023. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. Licensee states the facility has a backup generator.

LPA followed up on the facility's fire clearance for the staff living quarters in the garage and Licensee stated they thought it has been sent to The Department by the Fire Marshall already. LPA informed Licensee that it has not been received by CCL to date. Licensee attempted to contact the Fire Marshall and a recording stated that they were out until the first week of 12/2024. Licensee stated they will follow up with Code Enforcement on Monday.

LPA will return to complete annual inspection file review at a later time.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 03:23 PM - It Cannot Be Edited


Created By: Julie Florio On 11/22/2024 at 03:09 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: CHICO'S HOME
FACILITY NUMBER: 486803794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

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
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Based on observation, the licensee did not comply with the section cited above in ensuring the facility knives, scissors, and other sharp objects in the kitchen were inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2024
Plan of Correction
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Licensee to submit self-certification that they will ensure all items which pose a rick to clients in care will remain inaccessible to clients at all times to CCL by POC due date 11/23/3024.
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: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CHICO'S HOME
FACILITY NUMBER: 486803794
VISIT DATE: 11/22/2024
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Continued from LIC809C...

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 Personnel Report (updated)
  • LIC809D Emergency Disaster Plan (updated)

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.

Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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