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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804007
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:37:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/06/2024 01:37 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:INFINITI CARE HOME #1FACILITY NUMBER:
486804007
ADMINISTRATOR/
DIRECTOR:		FROLIAN DEVERAFACILITY TYPE:
735
ADDRESS:607 TRAVIS BLVDTELEPHONE:
(707) 771-1516
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
11/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Froilan Devera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 11/06/2024, at approximately 10:50 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Annual Continuation inspection and met with Froilan Devera, Administrator. Licensee, Carl Resurreccioa arrived at approximately 11:20 AM, and Licensee, Julie Martuscello arrived at approximately 11:40 AM.

At approximately 11:05 AM, LPA reviewed 4 staff files and 4 client files. 4 of 4 staff files reviewed had all then required documentation per regulation, including proof of current First Aid and CPR training. 4 of 4 client records reviewed were observed missing the LIC625 Needs and Services Plan which have not been updated and reviewed with each client and/or their respective responsible party within the last year as required per regulation. Additionally, 4 of 4 client records reviewed were missing a Consent for Emergency Medical Treatment. Further, Client 1 (C1) and Client 2 (C2) were missing a signed and dated LIC601 ID and emergency information form and the required CCL Personal Rights LIC613 form. Lastly, the LIC601 ID and emergency information form was missing for Client 3 (C3). (See LIC809D.)

Licensee states facility coordinates the residents' medical and dental appointments as needed and provides transportation to and from these visits. LPA reviewed residents' P&I records and medications and medication records which are all maintained in compliance with regulation.

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.

Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 01:37 PM - It Cannot Be Edited


Created By: Julie Florio On 11/06/2024 at 01:21 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: INFINITI CARE HOME #1
FACILITY NUMBER: 486804007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80070(a)

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80070 Client Records (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:
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Licensee to submit a current, signed and dated care plan for each client in care to CCL by POC due date 12/06/2024.
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Based on observation, interview, and record review the licensee did not comply with the section cited above in4 out 4 client records reviewed, which poses a potential health, safety and/or personal rights risk to persons in care.
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 Additionally, Licensee to submit self-certification ensuring that all other required docuements have been completed, signed and dated for each client to CCL by POC due date 12/06/2024.

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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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