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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:34:40 AM


Document Has Been Signed on 05/19/2023 11:34 AM - 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:DIZON, TIFFANYFACILITY TYPE:
740
ADDRESS:1000 GORDON LANETELEPHONE:
(707) 545-8213
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:15CENSUS: 10DATE:
05/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator, Nick AquinoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Plan of Correction visit and was greeted by staff, Myla Rublico. Administrator, Nick Aquino arrived later.

LPA is following up regarding deficiencies cited during the May 9, 2023 Annual Required inspection.

The following deficiencies have been corrected:
87555(b)(23) - Food has been repackaged and items are labeled
87555(b)(27) - Refrigerators have been cleaned.
87465(h)(5) - Medication is no longer being pre-poured
87463(c) - Resident reappraisals have been completed
87555(b)(8) - Food that is not good quality has been removed.
87303(a) - Facility has been cleaned and debris in the backyard was removed
87303(e)(2) - Water temperature is reading at 114F which is within regulation

Facility is being provided an extension regarding the following deficiencies until 5/26023:
1569.618(c)(3) - First Aid and CPR Certification class has been scheduled for 5/23/2024 and facility will provide LPA proof of certification by 5/26/2023
87507(c) - Responsible Party has been notified that Admission Agreement must be signed and will come to facility to complete. Administrator will also sign.

The following deficiencies have not been corrected and Civil Penalties are being issued:
87412(a) - Staff files are not in the facility
87412(d) - Licensee has not provided an update regarding the status of Administrator Certification
87465(h)(6) - Centrally Stored Medication Log has not been created or maintained

Civil Penalties totaling $2,100.00 are being issued for failure to clear deficiencies by their correction date. $100 per day may continue to be issued until deficiencies are cleared per Health and Safety Code 1568.0822(b)(1).
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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