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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486890081
Report Date: 02/12/2025
Date Signed: 02/12/2025 01:07:40 PM

Document Has Been Signed on 02/12/2025 01:07 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:GOOD SAMARITAN CARE HOME LLCFACILITY NUMBER:
486890081
ADMINISTRATOR/
DIRECTOR:		SKILLMAN, TROYFACILITY TYPE:
735
ADDRESS:364 PEPPER DRIVETELEPHONE:
(707) 643-3567
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alice Gipson, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver (CG) Alice Gipson. LPA spoke on the telephone with Administrator Troy Skillman who was unavailable for today's inspection. Good Samaritan Care home, LLC is Licensed as an Adult Residential Facility. Facility is a single story ranch house. Facility has an approved fire clearance for six (6) ambulatory clients between the ages of eighteen (18) through fifty-nine (59). Upon arrival, LPA was informed that there were three (3) clients in care and two (2) staff members on-site. Two (2) of the clients were away at day programs during the inspection. At approximately 9:20 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:30 AM, LPA toured the facility with Caregiver Gipson. All exits were clear and unobstructed. The fire extinguisher was last serviced and tagged on 1/19/2025. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected three (3) client bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. The Facility does not have an internet access device. A Technical Violation is being issued for not having an internet access device. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 1/11/2025. The facility does have emergency food and supplies to meet the "72-hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and operational.

Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 02/12/2025 01:07 PM - It Cannot Be Edited


Created By: Robert Frank On 02/12/2025 at 12:10 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: GOOD SAMARITAN CARE HOME LLC
FACILITY NUMBER: 486890081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1537.1(a)
Regulations
(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that at least one internet access device was dedicated and available for client use, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Administrator will self certify that at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use is on the facility premises by POC due date of 2/26/2025.
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:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2025 01:07 PM - It Cannot Be Edited


Created By: Robert Frank On 02/12/2025 at 12:23 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: GOOD SAMARITAN CARE HOME LLC
FACILITY NUMBER: 486890081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(7)(F)(G)
80075 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:
(F)Expiration date.
(G) Number of refills.

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 in three (3) out of three (3) LIC 622 Centrally Store Medication and Destruction logs for R1, R2 and R3 were not completed with Expiration Dates and Number of refills missing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator will submit completed LIC 622 Centrally Store Medication and Destruction logs for R1, R2 and R3 to Community Care Licensing by POC Due Date of 2/14/2025.
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:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


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: GOOD SAMARITAN CARE HOME LLC
FACILITY NUMBER: 486890081
VISIT DATE: 02/12/2025
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...Continued from 809

At approximately 10:15 AM, LPA reviewed three (3) client files. Three (3) of three (3) client files were found with all required documentation. LPA reviewed three (3) staff files. Three (3) of three (3) staff files had all required documents including proper training documentation. LPA spot checked Medication for three (3) clients. LPA observed all medications to be centrally stored. LPA observed that three (3) of three (3) residents medications were not properly documented in the LIC 622 Centrally Stored Medication and Destruction Records per Title 22 Regulations. This deficiency will be cited.

Troy Skillman’s Administrator Certification 7034431735 is current with an expiration date of 7/11/2025.

LPA requested the following documents be submitted to Community Care Licensing by 3/12/2025:



LIC 500 Personnel Report
LIC 308 Designation of Responsibility
LIC 610D Emergency Disaster Plan
LIC 400 Affidavit Regarding Client Cash Resources for Increased Value of Client Monies
LIC 402 Surety Bond Updated to reflect Increased Value of Client Monies

Exit interview conducted. Copy of report, LIC809Ds (Deficiency Pages) with plans of corrections, LIC9102 Technical Violation, Confidential Names (LIC811), and Appeal Rights discussed and provided to caregiver Gipson. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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