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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804219
Report Date: 12/06/2024
Date Signed: 12/06/2024 08:19:51 PM

Document Has Been Signed on 12/06/2024 08:19 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:VIEWMONT COTTAGEFACILITY NUMBER:
486804219
ADMINISTRATOR/
DIRECTOR:		SIMI, ANGELINAFACILITY TYPE:
740
ADDRESS:219 CORKWOOD STREETTELEPHONE:
(707) 287-0118
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 1DATE:
12/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Angelina Simi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Canela arrived unannounced and met with care staff April Cervantes, Administrator Angelina Simi arrived at the end of the visit.
During the course of a complaint investigation, LPA discovered the facility failed to report an incident that occurred on 11/25/2024 when resident R1 AWOL the facility. Facility had seven days to submit a written report to Community Care Licensing. Facility had another incident on 12/2 and stated they will be submitting that report on time. During todays visit LPA also observed some gadgets on the front door, back door and office door that can be used to prevent a door from opening. LPA asked Administrator to remove those immediately even if they are stated to not being used. LPA also requested the facility to remove the front gate latch that appears to have a key hole to possibly lock. LPA explained that even if they state they are not locking it, they may not use it unless they apply with CCL and the fire department and CCL approves for a locked perimeter. During today's visit LPA also found 1 staff working S1 who was fingerprint cleared but not associated. There was an additional staff S2 who has is also employed but was also fingerprint cleared and not associated. LPA verified both have fingerprint clearances but not properly associated to this facility. LPA went over procedures and provided the facility with our Regional office information to submit requests if they are having technical difficulties with the departments Guardian link. LPA explained failure to properly associate staff may result in civil penalties being assessed, although one was not issued today.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 08:19 PM - It Cannot Be Edited


Created By: Araceli Canela On 12/06/2024 at 03:31 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: VIEWMONT COTTAGE
FACILITY NUMBER: 486804219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2024
Section Cited
CCR
87211(a)(1)

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Reporting Requirements- A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name,
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Licensee/Administrator to ensure all reports as required by regulations are submitted to Licensing within required time frame. Licensee/Administrator to submit a written plan of how facility will ensure future compliance. POC due by 12/11/2024 attention LPA A Canela
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This requirement was not met. As evidenced by: Facility failed to submit the 11/25/24 incident report within the required time. This is a potential risk t the H&S of residents in care.
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Type B
12/09/2024
Section Cited
CCR87355(e)(2)

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87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.
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Facility to send a written plan on how they will ensure compliance and that all staff are properly fingerprint cleared and associated to the facility prior to working, residing or volunteering.
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This requirement was not met. As evidenced by: Facility failed to associate staff S1 and S2 who have a fingerprint clearance but are not associated to this facility to work. This is a potential risk t the H&S of residents in care.
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POC due date 12/9/2024 attention LPA Canela
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:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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