<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111253
Report Date: 06/13/2022
Date Signed: 06/14/2022 09:19:16 AM

Document Has Been Signed on 06/14/2022 09:19 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A STEP UPFACILITY NUMBER:
490111253
ADMINISTRATOR:MCCULLOCH, DEBBIEFACILITY TYPE:
772
ADDRESS:420 EAST COTATI AVENUETELEPHONE:
(707) 795-4336
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY: 12CENSUS: 7DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Debbie McCulloch - AdministratorTIME COMPLETED:
05:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator Debbie McCulloch. Some clients were present at the facility. Some clients at this facility have their own activities during the day and/or are working. There are activities planned for clients during the day if they want to participate.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 6/13/2022 with administrator Debbie McCulloch facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/2021 at the time of the visit. Carbon monoxide detector was operational during visit. Sample test of Smoke detectors was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the living room, however; during tour of facility LPA observed several unlocked toxins under clients’ bathrooms under sink. (see pictures, LIC 809-D). Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 113.3 degrees F and 150.8 degrees F in 1 out of 3 faucets falling out of Title 22 acceptable regulations of 105 to 120 degrees F. Client’s bathroom in the annex part of facility had a faucet with hot water temperature of 150.8 degrees F. (see LIC 809-D) Disaster Drills have been conducted often with the last one being conducted on 2/23/2022.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2022
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 6
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: A STEP UP
FACILITY NUMBER: 490111253
VISIT DATE: 06/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Infection Control:
Facility has submitted a mitigation program plan that has been approved for COVID-19. Posters have been placed at facility. Staff before coming into work is supposed to have temperature checked as well as clients temperatures to be check daily. Facility has PPE supply stored in the annex part of facility. There has beennew staff hired and/or new clients since COVID-19. Clients’ medications are stored and locked in medication cabinet inside office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available virtual visits and telephone calls when contacting with family members and others. Staff stated that they have had all PPE training required on file and staff had N-95 fit testing conducted.

In addition, LPA learned that facility had several cases of COVID. Staff and clients were sick, facility contacted Public Health. However, Department was never contacted and/or incident reports submitted. Cases occurred between 5/9/2022 and 5/25/2022. (see LIC 809-D), documentation

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.


Department is requesting Licensee to update the following documents and submit to CCL by 6/20/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
Copy of Lease Agreement &/or Deed
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/14/2022 09:19 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 06/13/2022 at 04:37 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: A STEP UP
FACILITY NUMBER: 490111253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81087(n)(4)
Buildings and Grounds
(n) Notwithstanding Section 81087(l), cleaning supplies, cleaning solutions and disinfectants may be made available to clients provided all of the following conditions are met: (4) The licensee ensures that products are inaccessible to any client for whom these products may pose a danger if readily available.

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 6 out of 6 unlocked toxins under client's bathrooms cabinet which poses an immediate health, safety or personal rights risk to persons in care. Clients' bathrooms at facility had several unlocked toxins under sink cabinet. (see pictures)
POC Due Date: 06/14/2022
Plan of Correction
1
2
3
4
During the visit administrator removed all toxins and locked in a closet that stores toxins in the living room by facility office. POC cleared.
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 1 out of 3 clients' bathrooms faucet which poses an immediate health, safety or personal rights risk to persons in care.During tour of facility, LPA observed with administrator and a staff that hot water in the annex unit of facility measure 150.8 in 1 out of 1 bathrooms.
POC Due Date: 06/14/2022
Plan of Correction
1
2
3
4
Facility to ensure that hotwater temperature is in compliance with Title 22 Regulation. Facility agrees to adjust hot water temperature into compliance and submit a self certification by 6/14/22. In addition, facility to log for 7 days hot water temperature in all 3 bathroom faucets and submit to the Department by 6/20/22 in order to clear this citation.
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:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/14/2022 09:19 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 06/13/2022 at 04:46 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: A STEP UP
FACILITY NUMBER: 490111253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81061
81061 Reporting Requirements

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview, & record review, the licensee did not comply with the section cited above in 7 out of 8 clients and 3 out of 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care. During month of May 2022 facility had several cases of COVID positive that were not reported to Department and/or incident reports filled.
POC Due Date: 06/27/2022
Plan of Correction
1
2
3
4
Facility to ensure that incident reports and SOC 341s will be submitted when needed. Facility to submit an incident report for clients and staff that were COVID positive in addition to a plan on how facility procedure will ensure that incident reports will be filed when needed by POC date of 6/27/2022 in order to clear this citation.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022


LIC809 (FAS) - (06/04)
Page: 6 of 6