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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803965
Report Date: 04/25/2024
Date Signed: 05/01/2024 08:29:27 AM

Document Has Been Signed on 05/01/2024 08:29 AM - 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:ANTIQUITY HOME, LLCFACILITY NUMBER:
486803965
ADMINISTRATOR/
DIRECTOR:		ORIBELLO, MARK & GRACEFACILITY TYPE:
735
ADDRESS:904 ANTIQUITY DRIVETELEPHONE:
(408) 313-0173
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Mark Oribello, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At approximately 12:30 PM, Licensing Program Analysts (LPAs) Dominic Tabolo and Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and met with Mark Oribello, Administrator. At approximately 1:00 PM, LPAs toured the building and grounds which was found to be clean and in good repair. LPAs observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured from 106.8 to 109.7 degrees F which is within regulation of 105 and 120 degrees F at four out of four faucets accessible to clients. Two of two fire extinguishers inspected on 05/30/2023 and were charged. Smoke detector and carbon monoxide interconnected signalling system was tested and found to be in working order. Disaster Drills are conducted monthly with the last drill conducted 04/07/2024. Advised licensee to ensure back shed is locked at all times, non-skid bath mats are required in all bath tubs/showers, and facility shall be kept in good repair at all times.

At approximately 1:45 PM, LPAs reviewed 4 of 4 Client records and 3 of 6 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files reviewed. Mark Oribello, Administrator Certificate 6023654735 is current with an expiration date of 12/30/2024. Inspected one out of four clients medications. LPAs and Administrator reviewed and observed medication records and medication count to be inaccurate. LPA's observed medication pre-poured for the evening. LPA's advised Administrator of deficiencies.




Continued on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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Document Has Been Signed on 05/01/2024 08:29 AM - It Cannot Be Edited


Created By: Stefanie Mutialu On 04/25/2024 at 03:07 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: ANTIQUITY HOME, LLC
FACILITY NUMBER: 486803965

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview, and record review, the licensee did not comply with the section cited above in LPAs observed medication records were found to be inaccurate, signatures were missing from medication records, medication count was inaccurate, and medication was pre-poured for the evening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee to submit self certification of a written plan of action. Self certification to be submitted to CCL by POC date of 04/26/2024. In addition licensee to conduct full medication record audit. Licensee to submit LIC9098 Proof of Correction form by 05/06/2024
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


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: ANTIQUITY HOME, LLC
FACILITY NUMBER: 486803965
VISIT DATE: 04/25/2024
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Continued from 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Updated copies of the following documents were received during visit to update facility file:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Facility Sketch


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.

This report was reviewed with Administrator and Appeal rights were given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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