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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803869
Report Date: 08/04/2023
Date Signed: 08/04/2023 05:08:12 PM

Document Has Been Signed on 08/04/2023 05:08 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:HYDEE'S CARE HOME LLCFACILITY NUMBER:
486803869
ADMINISTRATOR:RAMIREZ, HYDEEFACILITY TYPE:
735
ADDRESS:1175 JACK LONDON DRIVETELEPHONE:
(707) 704-8353
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ernesto Ramirez, CaregiverTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an Annual Required 1 Year inspection and met with caregiver Ernesto Ramirez (S1), LPA spoke with Administrator Hydee Ramirez who informed LPA that she is in Las Vegas at a conference and okayed caregiver to sign documents. Administrator informed LPA that she had clients, staff records and P&I with her and they are not at the facility. Caregiver Javoni Ramirez (S2) arrived at 10:40am.

Facility has a fire clearance for six(6) 4 ambulatory and 2 non-ambulatory clients. All six (6) smoke alarms were working properly when checked during the inspection; The facility has combined smoke alarms with carbon monoxide detector. Fire extinguisher, was not tagged as required. All exits were clear and unobstructed.

LPA toured the facility with caregiver Ernesto Ramirez. The hot water was checked at 107.6F which is within regulation. LPA observed a sufficient supply of food. The LPA observed a sufficient supply of cleaners, hygiene products, and paper products. Resident medications are locked up in a cabinet making them inaccessible to clients in care. LPA observed a sufficient supply of linen for client use. The facility has sufficient furnishings for clients use.

During the tour LPA observed the following deficiencies:
  • broken lock on cabinet containing staff medication
  • unlocked toxin (raid bug spray)(Ajax under kitchen sink)
  • scissors and a knife in an unlocked drawer, and scissors in a cup on top cabinet shelf
  • knife storage box unlocked in an unlocked cabinet
  • lighter in an unlocked drawer
  • fire extinguisher on kitchen floor not tagged as required
  • toxins, lighter, saws, and power tools in an unlocked garage
  • side yard gate locked with pad lock
  • staff and resident files are not at the facility ADM stated she has the records with her in Las Vegas

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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 08/04/2023 05:08 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/04/2023 at 02:23 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: HYDEE'S CARE HOME LLC
FACILITY NUMBER: 486803869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

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 by having cleaning solutions, and other toxins accessible to clients in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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Administrator agreed to conduct in-service with all staff about the importance of storing the cleaning solutions inaccessible to clients in care, and email a copy of the attendance sheet to CCLD no later than the POC date. Administrator will lock toxins, saws, and gardening power tools, and email photos to CCLD no later than the POC date.
Type A
Section Cited
CCR
80087(g)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 by having scissors, knives, saws, gardening tools accessible to clients in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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Administrator agreed to lock scissors in locked cabinet, lock knives in knife lock box and keep locked at all times. Administrator will conduct in-service with all staff and email a copy of staff attendance to CCLD no later than the POC date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 08/04/2023 05:08 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/04/2023 at 02:23 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: HYDEE'S CARE HOME LLC
FACILITY NUMBER: 486803869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

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 by having staff medication in a cabinet with a broken lock which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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Administrator agreed to have locked repaired on broken cabinet and conduct in-service with all staff on the importance of medication storage and email a signed copy of staff attendance. Administrator will email photos of repaired cabinet to CCLD no latr then POC date.
Type A
Section Cited
CCR
80020(a)(2)
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. (2) Prior to the use of secured perimeters, an applicant or licensee for an Adult Residential Facility or Group Home shall meet the fire clearance approval requirements of Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Section 56072(d) and (h).

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 by having a pad lock on the side yard gate which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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Caregiver removed lock, deficiency cleared during visit.

Civil Penalties are also being assessed in the amount of $500 due to zero tolerance citation issued.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


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: HYDEE'S CARE HOME LLC
FACILITY NUMBER: 486803869
VISIT DATE: 08/04/2023
NARRATIVE
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Continue from LIC809

The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be orderly during the visit. The LPA observed that clients rooms, common areas, hallways, and bathrooms had sufficient lighting for clients in care.

LPA is requesting the following forms be updated and submitted to CCL by 8/11/23:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond in Required Amount
· Infection Control Plan If updated


Civil Penalties are also being assessed in the amount of $500 due to zero tolerance citation issued.

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 conducted and copy of report and appeal rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9
Document Has Been Signed on 08/04/2023 05:08 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/04/2023 at 04:08 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: HYDEE'S CARE HOME LLC
FACILITY NUMBER: 486803869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)(d)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having client records at the facility for record review which poses a potential health and safety risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Administrator will email a copy of all 3 residents complete file to CCLD no later then the POC date.
Type B
Section Cited
CCR
80075(B)(f)
80075 Health Related Services
(B) All staff training shall be documented in the facility personnel files.
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with administrator, the licensee did not comply with the section cited above by not having staff files available to conduct a record review which poses a potential health and safety risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Administrator will email a complete copy of staff file to CCLD no later than the POC date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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