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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111253
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:30:50 PM

Document Has Been Signed on 07/25/2024 01:30 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:A STEP UPFACILITY NUMBER:
490111253
ADMINISTRATOR/
DIRECTOR:		DEBBIE MCCULLOCHFACILITY TYPE:
772
ADDRESS:420 EAST COTATI AVENUETELEPHONE:
(707) 795-4336
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY: 12CENSUS: 6DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Debbie McCulloch. Facility contact information was reviewed. Facility is a Social Rehabilitation Program for Adults with Mental Health and Substance Abuse Disorders.

At approximately 10:00am LPA and House Manager toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA observed that there were two locked closets and two locked freezers located in the facility's Annex. Per Admin, these closets and freezers are used for emergency food storage and bulk item overflow. LPA confirmed that the locked closets and refrigerators store the facility's extra food and bulk supplies. Some food items stored in Annex were found to be expired: canned goods, boxed muffin mix, cereal bars, and packaged Little Debbie snack cakes. Admin discarded identified expired food items with LPA present. LPA advised Admin to do an audit of entire overflow snack and canned food storage to discard expired items. All food stored in the main building kitchen is unlocked and free for residents to use to make meals. Snacks are readily available by request and stored in staff office. Cabinet containing cleaning supplies was locked. Sharp knives locked in staff office.

All bedrooms were equipped with lighting, night stand, and chest of drawers. LPA advised each resident needs to have a lamp for use in their room. All bedrooms were clean. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured at 108.2, 117.3 and 106.1 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/9/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drill was conducted on 4/9/2024. LPA advised Admin that drills need to be conducted quarterly.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A STEP UP
FACILITY NUMBER: 490111253
VISIT DATE: 07/25/2024
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Continued from 809...

At approximately 11:00am LPA conducted review of five [5] staff records. All required documentation present. At approximately 11:30am LPA conducted a review of six [6] resident records. All required documentation present.



At approximately 12:00pm cash resources were reviewed. No deficiencies.

At approximately 12:15pm LPA and House Manger conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Bubble pack for R1 missing one tab of Gabapentin 800mg filled 6/19/2024, count was off by one tab. However, staff could not produce resident chart note indicating a pill was accidentally either punched out or dropped on the floor or produce a corrected Centrally Stored Medication Log. R1's Buprenorphine 7.5mg bubble pack filled on 7/9/2024 labeled with AM sticker and 8 mg Buprenorphine bubble pack filled on 7/9/2024 labeled with both an AM and PM sticker not listed on Centrally Stored Medication log. R1's Olanzipine 15mg listed on CSML with RX number of 7.5 mg Olanzipine and 7.5mg Olanzipine listed on CSML with RX number of 15mg Olanzipine (the RX numbers were swapped) (deficiency cited, see 809D).

Debbie McCulloch Administrator Certificate 7016280735 expires 7/18/2024. All fees are current as of this time. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with staff. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Admin had to leave facility for an appointment. Admin gave staff permission to sign report. Exit interview conducted with staff and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2024 01:30 PM - It Cannot Be Edited


Created By: Christi Coppo On 07/25/2024 at 01:06 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: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and staff observation and record review, the licensee did not comply with the section cited above in that Bubble pack for R1 missing one tab of Gabapentin 800mg filled 6/19/2024, count was off by one tab. However, staff could not produce resident chart note indicating a pill was accidentally either punched out or dropped on the floor or produce a corrected Centrally Stored Medication Log. R1's Buprenorphine 7.5mg bubble pack filled on 7/9/2024 labeled with AM sticker and 8 mg Buprenorphine bubble pack filled on 7/9/2024 labeled with both an AM and PM sticker not listed on Centrally Stored Medication log. R1's Olanzipine 15mg listed on CSML with RX number of 7.5 mg Olanzipine and 7.5mg Olanzipine listed on CSML with RX number of 15mg Olanzipine (the RX numbers were swapped), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Facility to submit to CCL a plan to train all staff on how to maintain accurate medication logs. The plan to train staff is due by plan of correction due date of 7/26/2024. Completed staff training to be completed no later than 8/8/2024. Training log to be submitted to CCL and contain name of trainer, hours completed, name of course, date of attendance, and name of attendees.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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