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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108916
Report Date: 10/05/2022
Date Signed: 10/05/2022 01:04:26 PM

Document Has Been Signed on 10/05/2022 01:04 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 COUNTRY HOMEFACILITY NUMBER:
490108916
ADMINISTRATOR:NAVARRO, LORAFACILITY TYPE:
735
ADDRESS:341 MILLBRAE AVENUETELEPHONE:
(707) 585-0607
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 5DATE:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Lora Navarro (Administrator)TIME COMPLETED:
01:19 PM
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Licensing Program Analyst (LPA) Marisol Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator, Lora Navarro and another staff.

LPA arrived at the facility and was not screened by Administrator. TA advisory was issued for Administrator and we discussed the importance of screening visitors. However, Facility continues to screen clients for Covid-19 daily and maintain documentation. Facility is allowing indoor visitations, each client has their private room and is able to serve meals and deliver medications. LPA observed that staff were wearing masks during this visit. LPA/Administrator conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least twice a day. LPA confirmed with Administrator that facility was conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. Facility staff have been trained on PPE protocols and has been N-95 fit tested.

Facility maintains a 30 day supply of medication. All clients do not attend to day program due to health concerns; LPA and Administrator discussed activities and the facility provides activities. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has submitted their Covid Mitigation Plan and approved on 4/29/21. Facility submitted their Infection Control Plan to CCL for review. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff. Staff continue to receive training on infection control and Personal Protective Equipment (PPE).

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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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 COUNTRY HOME
FACILITY NUMBER: 490108916
VISIT DATE: 10/05/2022
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Continued from LIC809...

During today's visit, LPA also followed up in an incident report, discharge documents and 30-day eviction notice issued on 9/27/22 to client (C1) due to a significant decline in their health. On 9/29/22 LPA received an email from NBRC Service Coordinator notifying CCL that supplement staffing have been approved for up to 124 hours effective 10/1/22 for four hours per day until they find a placement. On 10/3/22 Administrator submitted a staff schedule indicating staff coverage.

At approximate 12:42pm LPA/Administrator observed that 1 out of 1 fire extinguisher were last serviced on May 5, 2021. Administrator contacted the Fire service company.

Administrator to submit updates of the following documents by 10/22/2022: LIC 500 Personnel Summary


affidavit regarding client/resident cash resources (LIC400) and surety bond.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies) may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2022 01:04 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/05/2022 at 12:51 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 COUNTRY HOME
FACILITY NUMBER: 490108916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)

80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in 1 out of 1 fire extinguisher was not serviced since May 5, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Administrator called immediately the Fire Department to have fire extinguisher serviced. Administrator agreed to submit Proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department. POC due date 10/6/2022
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022


LIC809 (FAS) - (06/04)
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