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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 05/23/2025
Date Signed: 05/23/2025 03:48:00 PM

Document Has Been Signed on 05/23/2025 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MC HUGH CARE HOMEFACILITY NUMBER:
490108000
ADMINISTRATOR/
DIRECTOR:		DIZON, TIFFANYFACILITY TYPE:
740
ADDRESS:1000 GORDON LANETELEPHONE:
(707) 545-8213
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
05/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Rodrigo Gallardo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year inspection and was greeted by Caregiver (CG) Rodrigo Gallardo. Mc Hugh Care Home is licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for fifteen (15) Residents. Eleven (11) Residents can be non-ambulatory. There is a hospice waiver for one (1) Resident. Upon arrival, LPA was informed that there were eight (8) Residents in care and two (2) staff members on-site. At approximately 9:15 AM, LPA reviewed the Facility's Staff Roster and observed that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:20 AM, LPA toured the facility with CG Gallardo. All exits were clear and unobstructed. The facility has three (3) fire extinguishers. Two (2) extinguishers were last serviced in 5/2024. One (1) extinguisher was observed to be last serviced in 6/2023. All extinguishers need to be serviced and tagged annually. This deficiency will be cited. The fire alarm and sprinkler system was serviced in 12/2024. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected four (4) Resident bedrooms and observed all to have sufficient lighting and furnishings as required per Title 22 Regulations. The sliding screen doors in bedroom one (1) and in bedroom four (4) were observed to be damaged. This deficiency will be cited. LPA observed a badly broken window in bedroom seven (7). The window was observed to have been partially covered with cardboard and duct tape. This deficiency will be cited. The facility was previously cited for the same deficiency on 7/2/2024. As the deficiency has been cited twice in under twelve (12) months, a Civil Penalty will be assessed for the facility not being in good repair.

Continued on 809-C...
Victoria BertozziTELEPHONE: (707) 588-5059
Robert FrankTELEPHONE: (707) 588-5026
DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000
VISIT DATE: 05/23/2025
NARRATIVE
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...Continued from 809

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed two sauce containers that were opened and partially used in the kitchen pantry. Both sauces required refrigeration after opening. This deficiency will be cited. LPA further observed in the same pantry several food cans that had rodent feces on their top. This deficiency will be cited in Complaint 21-AS-20250421123325. In the closet outside of bedroom two (2) LPA observed unsecured prescription medication for a Resident who is no longer admitted to the facility. This deficiency will be cited. The facility was previously cited for the same deficiency on 12/6/2024. As the deficiency has been cited twice in under twelve (12) months, a Civil Penalty will be assessed for the unsecured medication. All other toxins were observed to be stored inaccessible to Residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is not conducting fire and emergency drills per regulation with the last disaster drill having taken place in July, 2024. This deficiency will be cited. 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 observed to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. LPA observed spider webs and dirt on the floors of the facility's common areas.

At approximately 11:45 AM, LPA reviewed four (4) Resident files. LPA observed that Three (3) of four (4) Residents (R2,R4,R5) did not have current appraisal & needs service plans. For R2, R4 and R5 the last appraisal & needs service plan was dated 5/9/2023. One (1) Resident (R3) did not have any appraisal & needs service plan or signed Personal Rights documents in their file. These deficiencies will be cited. LPA reviewed two (2) staff files. Two (2) staff members (S1,S2) did not have proof of annual training on file. This deficiency will be cited. One (1) staff member (S1) did not have current First Aid or CPR certification. This deficiency will be cited. LPA spot checked Medication for three (3) Residents. LPA observed all medications to be centrally stored, secure and with proper documentation. Resident’s monies for personal and incidental items are not maintained by the facility.

Continued on 809-C(2)...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert FrankTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000
VISIT DATE: 05/23/2025
NARRATIVE
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...Continued from 809-C

Administrator Tiffany Dizon's Administrator Certification is not current.

LPA requested the following documents be submitted to Community Care Licensing by 6/23/2025:

LIC 500 Personnel Report
LIC 308 Designation of Responsibility
LIC 610E Emergency Disaster Plan

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, LIC 421FCs, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to CG Gallardo. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert FrankTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/23/2025 03:48 PM - It Cannot Be Edited


Created By: Robert Frank On 05/23/2025 at 02:13 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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that the fire extinguisher in the garage/laundry area was last certified on 6/6/2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
1
2
3
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Licensee to provide photographic proof to Community Care Licensing that the fire extinguisher has been serviced by the POC due date of 6/20/2025
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the sliding screen doors in bedroom one (1) and in bedroom four (4) were damaged which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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2
3
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Licensee to provide photographic proof to Community Care Licensing that both noted screen doors have been repaired by the POC due date of 6/20/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/23/2025 03:48 PM - It Cannot Be Edited


Created By: Robert Frank On 05/23/2025 at 02:13 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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that staff member (S1) did not have current First Aid or CPR certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee to provide proof of 1st Aid and CPR certification for staff member S1 to Community Care Licensing by the POC due date of 6/20/2025.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that two (2) staff members (S1,S2) did not have proof of annual training on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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2
3
4
Licensee to provide proof that staff members S1 and S2 have begun their annual training to Community Care Licensing by POC due date of 6/20/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/23/2025 03:48 PM - It Cannot Be Edited


Created By: Robert Frank On 05/23/2025 at 02:13 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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that Resident R3 did not have signed Personal Rights documents in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee to provide signed Personal Rights documents for resident R3 to Community Care Licensing by POC due date of 6/20/2025.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that there were two sauce containers that were opened and partially used in the kitchen pantry. Both sauces required refrigeration after opening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
1
2
3
4
Licensee to provide proof to Community Care Licensing that staff members S1 and S2 have taken food safety training by POC due date of 6/20/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/23/2025 03:48 PM - It Cannot Be Edited


Created By: Robert Frank On 05/23/2025 at 02:13 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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that Residents (R2,R4,R5) did not have current appraisal & needs service plans. For R2, R4 and R5 the last appraisal & needs service plan was dated 5/9/2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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2
3
4
Licensee will submit to Community Care Licensing updated appraisal & needs service plansvfor R2, R4 and R5 by POC due date of 6/20/2025.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that the facility is not conducting fire and emergency drills per regulation with the last disaster drill having taken place in July, 2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
1
2
3
4
Licensee to submit to Community Care Licensing proof that the facility has conducted a fire and emergency drill by POC due dateof 6/20/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/23/2025 03:48 PM - It Cannot Be Edited


Created By: Robert Frank On 05/23/2025 at 02:29 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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 bubble packs of the medication Geodon 80mg for R1 was left unsecured in the hallway closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
Licensee will conduct medication training with staff members S1 and S2 and provide proof of training to Community Care Licensing by POC due date of 5/26/2025.
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that there was a badly broken window in bedroom seven (7). The window was observed to have been partially covered with cardboard and duct tape which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
Licensee to send photographic proof to Community care Licensing showing that the broken window has been replaced by POC due date of 5/26/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (707) 588-5059
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (707) 588-5026
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
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