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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804110
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:48:59 PM

Document Has Been Signed on 09/01/2023 03:48 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ZINA'S CARE HOME IFACILITY NUMBER:
486804110
ADMINISTRATOR:LEE, ZINA M.FACILITY TYPE:
735
ADDRESS:3000 CHESTNUT CTTELEPHONE:
(707) 434-1117
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Rhoda Venkaiya, Lead StaffTIME COMPLETED:
04:00 PM
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On 9/1/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Rhoda Venkaiya. Administrator, Zina Lee was contacted but unable to attend visit. The facility currently provides care for 4 clients, 2 of which were present and 2 of which was attending day program at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/2/2022. LPA provided reminder for facility to re-inspect the extinguisher as final date before expiration is within 24 hours of visit. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food stored in the garage. Food stored in the kitchen refrigerator were stored properly with appropriate labeling and dates. There was a supply of linens, hygiene products and paper products available for clients located in the hallway.

Upon inspection of client bedrooms LPA observed clients speaking on the phone with family or lounging in their bedroom for leisure. LPA spoke with client who appeared comfortable and spoke positively of the facility with no concerns at the time of visit. LPA conducted a file review for 4 out of 4 clients. Administrator is currently in the process of updating clients' (C1 & C2) Physician's Reports. Both of which have not had any major changes of conditions however, Administrator agrees to submit updated documents to CCLD once completed. The Needs & Service Plans for all clients have been updated as of June 2023 but require signatures from Administrator. Technical Assistance provided. LPA conducted a sample file review for staff and found all staff to have appropriate training and 1st aid & CPR certification on file. In addition, facility conducts emergency evacuation drills with staff and clients every three months.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ZINA'S CARE HOME I
FACILITY NUMBER: 486804110
VISIT DATE: 09/01/2023
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LPA conducted a spot medication count for clients and found several medications for client (C1) not properly recorded on the Centrally Stored Medication Record. In addition, LPA found C1's medications to be prepared over 24 hours before administering. LPA requested for Administrator to contact C1's Primary Care Provider, request for a doctor's order and request an exception for medication administration preparation. Administrator also informed LPA that a medication administration assistance and record keeping training has been scheduled for all staff to complete.

Administrator, Zina Lee's Administrator Certification 6012974735 is currently active until 11/30/2024.

LPA requested the following documents be sent to CCL by COB 10/1/2023:
LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC309 Administrative Organization
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Surety Bond
Control of Property


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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/01/2023 03:48 PM - It Cannot Be Edited


Created By: Dominic Tobola On 09/01/2023 at 03:18 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: ZINA'S CARE HOME I
FACILITY NUMBER: 486804110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed several medications for client (C1) that were not properly input on the Centrally Stored Medication Records. In addition, medications for C1 were prepared over 24 hours in advance both of which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Administrator indicated that they have scheduled a medication training for all Direct Support Staff on medication administration assistance and recording. Administrator to submit proof of training once completed. In addition, LPA requesting for Administrator and Lead Staff to conduct full medication audit to ensure all client medications are reconciled on Centrally Stored Medication Records. LIC9098 Proof of Corrections form to be submitted to CCL by 9/15/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
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