486803794-1-2-2025-21-AS-JFLO-DCJVB7-20250102151704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803794
Report Date: 01/02/2025
Date Signed: 01/02/2025 03:17:16 PM

Document Has Been Signed on 01/02/2025 03:17 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 HOME		FACILITY NUMBER:	486803794
ADMINISTRATOR/ DIRECTOR:	MORALES, CECILIA		FACILITY TYPE:	735
ADDRESS:	832 WORLEY RD		TELEPHONE:	(707) 688-5075
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 4		CENSUS: 3	DATE:	01/02/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Cecilia Morales, Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 12:00 PM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a Case Management - Annual Continuation 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. At approximately 12:10 PM, LPAs initiated a brief facility tour with Licensee to follow up on issues noted during the initial annual inspection visit on 11/22/2024. Water temperature in the third bathroom tested at 105.9 degrees F during today's inspection which is within the allowable range of 105 to 120 degrees F per Title 22 regulation. All sharps and items which could pose a risk to clients were observed locked and inaccessible to clients in care. LPAs inspected facility's food supply which was observed to be free from expired items and was in compliance with regulation. All the required posters were observed hanging in a conspicuous common area of the facility. The facility telephone was tested and operational during inspection. The shed in the backyard was observed unlocked. LPAs advised Licensee to ensure the shed remains locked at all times to remain in compliance with regulation. Licensee locked the shed immediately and agreed to ensure it remains locked. Licensee states the facility conducts bi-annual disaster drills, with the most recent drill conducted 9/2024. LPAs reminded Licensee that disaster drills are now required to be conducted on a quarterly basis. LPAs followed up on the facility's fire clearance for the staff living quarters in the garage, and Licensee provided LPAs with the updated signed and approved fire clearance from the fire marshal stating that the bedroom in the garage is approved for staff use only. At approximately 12:40 PM, LPAs began file review. Five (5) staff and three (3) client files were reviewed. continued on LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

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: CHICO'S HOME	FACILITY NUMBER: 486803794
	VISIT DATE: 01/02/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809...

All five (5) staff files reviewed have all the required paperwork per regulation including proof of CPR and first aid training certificates. Three (3) of three (3) client files reviewed were observed to have all the required paperwork per regulation. However, LPAs observed Client 1 (C1) missing a signed appraisal needs and services plan, and Client 2 (C2) missing a consent for emergency treatment, (see LIC809D).

At approximately 1:50 PM, LPAs reviewed medications and medication records which were found to be stored and maintained within regulation. LPAs advised Licensee to ensure that start dates for medications are recorded accurately in clients' centrally stored medication records. P & I was inspected and was observed to be stored and maintained in compliance with regulation.

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)
Copy of Fire Clearance (updated)
Proof of most recent file drill completed

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: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/02/2025 03:17 PM - It Cannot Be Edited

Created By: Julie Florio On 01/02/2025 at 02:55 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: 01/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(a)

Client Records 80070(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in two instances where a client was missing a care plan and another was missing a consent for emergency medical treatment, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof that the care plan and consent for emergency treatment have both been completed and signed by the clients or their responsible parties to CCL by POC due date 01/31//2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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: 01/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3