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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107871
Report Date: 08/28/2023
Date Signed: 08/28/2023 09:52:32 PM

Document Has Been Signed on 08/28/2023 09:52 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:SARAH'S GROUP HOME FOR YOUNG ADULTSFACILITY NUMBER:
490107871
ADMINISTRATOR:LAWRENCE, SARAHFACILITY TYPE:
735
ADDRESS:8019 ADRIAN DRIVETELEPHONE:
(707) 795-9701
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 3DATE:
08/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cozy Edmondson-CaregiverTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required -1 Year inspection, on 8/28/23 at approximately 3:00pm, and met with caregiver, Cozy Edmondson. The caregiver contacted lead House Manager/Caregiver Blanca Martinez. Currently there are three(3) clients in care.

LPA reviewed three(3) clients files. Client files were complete. LPA reviewed three(3) staff files. All staff had criminal record clearance.

Facility was found to be clean, orderly, and at a comfortable temperature with exits free from obstruction. Hot was checked at 114. degrees Fahrenheit. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Facility has a sufficient supply of personal protective equipment(PPE).

Medications are locked up making them inaccessible to clients in care. All smoke alarms, which include carbon monoxide detectors were working properly during the LPA's inspection. Food supply is sufficient. Fire extinguishers, two(2), were serviced and tagged as required-expires 8/9/24.Bathrooms were clean.

One(1) out of three(3) staff lacked required first aid. This deficiency will be cited, 80075(f) Health Related Services - Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross, see LIC809D.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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Document Has Been Signed on 08/28/2023 09:52 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/28/2023 at 05:13 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: SARAH'S GROUP HOME FOR YOUNG ADULTS
FACILITY NUMBER: 490107871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(b)(2)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, S3 answered the door without a mask on, the facility is caring for a covid positive client at this time. Facility is not following infection control procedures, wearing a mask as required, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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Licensee to ensure all staff are following the facility's infection control plan, wearing appropriate PPE as required. Review infection control procedures with all staff and ensure that staff are complying as needed/required. Submit proof of training by 9/8/23. Submit plan of correction by 8/29/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2023 09:52 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/28/2023 at 05:13 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: SARAH'S GROUP HOME FOR YOUNG ADULTS
FACILITY NUMBER: 490107871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation (interview)and (record review)], One(1) out of three(3) staff lacked required first aid, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Licensee to ensure that all staff have required first aid, and CPR certification, ensure that S2 obtains first aid as a direct caregiver. S2 can't be left alone with clients until S2 has current first aid and CPR certification. Submit a copy of S2's certification. POC due 8/31/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


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: SARAH'S GROUP HOME FOR YOUNG ADULTS
FACILITY NUMBER: 490107871
VISIT DATE: 08/28/2023
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Staff, S3, answered the door without a mask on, the facility is caring for a covid positive client at this time. Facility is not following infection control procedures. This deficiency will be cited, Infection Control - 85095.5(b)(2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection, see LIC809D.

LPA requested the following documents to be sent to Licensing by 9/28/23.
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Surety Bond-if handling client cash
Emergency Disaster Plan (LIC 610D)-review and update as/if needed- submit a copy
Infection Control Plan-update as needed- submit


The following deficiency was cited under Title 22, Division 6 of the California Code of Regulations:

Exit interview conducted with Caregiver/House Manager, Blanca Martinez.
Appeal Rights provided to Blanca Martinez.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
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