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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803926
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:53:08 PM


Document Has Been Signed on 01/30/2024 02:53 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:EVAS CARE HOMEFACILITY NUMBER:
486803926
ADMINISTRATOR:MULDER, EVAFACILITY TYPE:
740
ADDRESS:319 ATLANTIC AVETELEPHONE:
(510) 890-8777
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: DATE:
01/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Eva Mulder, AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management. However, Administrator was not at the facility. Administrator Eva Mulder, arrived at approximately 1:50pm. Facility currently has zero residents in care. Facility has only one resident in care and they are in currently in a dementia care facility because the resident's care needs have changed such that they need supervision beyond what facility can provide.

On 1/02/2024 facility submitted an Incident Report indicating resident in care was attempting to flee the facility and exhibiting suicidal ideation, on 12/31/2023. Admin called emergency services and the resident was taken to the hospital. Resident has not returned to the facility.

Per LPA phone interview with Admin, and LPA review of resident's monthly medication log, resident has been out of certain medications since November 2023, these medications include: metformin, gabapentin, and propranolol. Per conversation with Admin, Admin contacted responsible party to refill metformin, gabapentin, and propranolol. Admin stated that resident's responsible party did not provide any refills and Admin did not follow up with doctor. Per Admin's conversation with resident's doctor, doctor stated she would not refill any medication until resident is seen in-person. Admin failed to insure resident had medication per doctors orders. Resident is currently in a different dementia care facility. Admin is unaware of resident's discharge date from the hospital; it is not yet determined if prolonged failure to provide medication is the reason for hospitalization. LPA will obtain further information and follow up.

Per resident's Physician's Report resident is not able to independently administer their own prescription medications, their own injections, perform their own glucose monitoring, administer their own PRNs, or store their own medications. Per resident's Care Plan, resident needs insulin and will require reminders and supervision of insulin injections. This is in direct contradiction to what is indicated on resident's Physician's report. LPA discussed with Admin this discrepancy and how running out of medications can be prevented or mitigated. LPA discussed importance of reviewing residents' Physician's Report prior to admission to ensure the facility can meet the required care needs of residents as well as conduct a pre-appraisal.

Continued on 809...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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: EVAS CARE HOME
FACILITY NUMBER: 486803926
VISIT DATE: 01/30/2024
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Continued from 809C...

Per Title 22 regulation 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents (deficiency cited, see 809D).

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

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/30/2024 02:53 PM - It Cannot Be Edited

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: EVAS CARE HOME
FACILITY NUMBER: 486803926

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
87465(a)(1)

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87465 (a)(1) A plan for incidental medical and dental care shall be developed by each facility.... shall provide for assistance in obtaining such care, by... licensee shall arrange...for medica...care appropriate to the conditions and needs of residents. This requirement not met as eveidneced by:
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Admin to submit LIC9098 self-certifying plan of action for ensuring all residents receive their prescribed medication per their doctor's orders as well as ensure all prescribed medications are present before admission of residents to facility.
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Based on LPA record review and interview with Administrator, Admin failed to insure resident had and received medications per doctors orders, which poses a potential health, safety or personal rights risk to persons in care.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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