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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111253
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:43:24 PM

Document Has Been Signed on 07/13/2023 04:43 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:A STEP UPFACILITY NUMBER:
490111253
ADMINISTRATOR:MOORE, SHANICEFACILITY TYPE:
772
ADDRESS:420 EAST COTATI AVENUETELEPHONE:
(707) 795-4336
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY: 12CENSUS: 7DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Program Director, Debbie McCullochTIME COMPLETED:
04:50 PM
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At approximately 2:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 year Visit and met with Program Director, Debbie McCulloch. Facility is a Social Rehabilitation Program that provides care and assistance for Adults with Mental Health and Substance Abuse Disorders. Facility has an approved fire clearance and capacity for 12 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 6 clients in care and 4 staff members on-site.

At approximately 2:25PM, LPA reviewed the facility's staff roster with Program Director. During review, LPA discovered that Staff Member 1 (S1) and Staff Member 2 (S2) were fingerprint cleared, but not associated to the facility as required. LPA contacted the Regional Office and confirmed the fingerprint clearance and association statuses of S1 and S2 to the facility. Facility sent the association paperwork to the Regional Office today, 07/13/2023. LPA confirmed with the Regional Office that the paperwork had been received.
**Program Director understands that a Civil Penalty is not being issued today for S1 and S2 because their association paperwork has been received by the Regional Office to be processed.**

LPA conducted a walk-though of the facility with Program Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility is a one story building with an Annex attached. Main House has with 3 bedrooms, 3 bathrooms, a kitchen, dining room, living room, and office spaces. Annex has 3 bedroom and 1 bathroom. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to Clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Client use.
The facility's last fire drill was conducted May 2023. Facility's fire extinguishers were last inspected August 2022.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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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: 07/13/2023
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Continued from LIC809

LPA reviewed two incident reports with Program Director. Incident Reports reviewed were self-reported and submitted to CCL.

Incident Report 1: CCL received an incident report on 03/06/2023. Report states that on 03/04/2023, Client 1 (C1) ran out of their medication. Facility made all appropriate notifications per regulation.
LPA and Program Director discussed C1 and reviewed documents. Review of C1's Physician Report shows that C1 is able to administer and store their own medication. LPA was informed that C1 manages their own prescriptions and the medication ran out due to C1 switching pharmacies. Since the incident, facility has started to provide reminders for C1 to refill their medications so they do not run out.

Incident Report 2: CCL received an incident report on 03/06/2023. Report states that on the morning of 03/06/2023, Client 2 (C2) was observed to not be in their room. Facility cameras showed that C2 left the facility the night before on 03/05/2023 without staff knowledge. Facility made all appropriate notifications per regulation.
LPA and Program Director discussed C2 and reviewed documents. Review of C2's Physician Report shows that C2 was able to leave the facility unassisted. LPA was informed that C2's conservator and case manager decided to have them discharged from the facility in March 2023. At this time, C2 has not been found. Facility has since installed a Ring camera and plans on installing an alarm system to notify staff when a client is leaving the facility.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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