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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111817
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:21:23 PM

Document Has Been Signed on 09/24/2024 12:21 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:LAUGHLIN COUNTRY HOMEFACILITY NUMBER:
490111817
ADMINISTRATOR/
DIRECTOR:		LA DOW, JEFFFACILITY TYPE:
735
ADDRESS:2565 LAUGHLIN ROADTELEPHONE:
(707) 576-1409
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Licensee Jeff La DowTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and found no one present at the facility. LPA spoke to licensee and was informed licensee was at their other facility waiting for a repair man. Licensee advised LPA either they or the other licensee will be arriving shortly. While waiting, LPA toured outside of facility. Shaded outdoor activity area plentiful. Licensee repairing deck, piles of wood mostly neat and organized; however LPA did observe a few of the old boards with nails protruding out, in pile of wood scraps on front lawn. Pile of wood scraps on front lawn has pieces of wood that are fragmented and splintered, presenting a possible hazard for residents. LPA was greeted by Licensee Jeff La Dow at approximately 10:00am. LPA and licensee discussed ensuring splintered wood scraps are immediately disposed of while repairing the deck.

At approximately 10:15am LPA and Admin 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. Food was found to be stored in a safe manner with open items covered. Cabinet containing cleaning supplies was locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 105.3 and 105.2 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 4/17/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 7/19/24.


Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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: LAUGHLIN COUNTRY HOME
FACILITY NUMBER: 490111817
VISIT DATE: 09/24/2024
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Continued from 809...

At approximately 11:00am LPA conducted a review of 5 resident records. No deficiencies cited.



At approximately 11:30am LPA conducted review of 3 staff records. S1 did not have a Health Screen on file (deficiency cited, see 809D). LPA and licensee discussed keeping staff training current annually.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked box. No deficiencies. Client cash resources were also reviewed. No deficiencies.

Jeff La Dow Administrator Certificate 7034461735 expires 4/13/2026. All fees are current as of this time.



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

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 Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with licensee and a copy of this report was given.

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

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 14
Document Has Been Signed on 09/24/2024 12:21 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/24/2024 at 11:56 AM
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: LAUGHLIN COUNTRY HOME
FACILITY NUMBER: 490111817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA and licensee observation and record review, the licensee did not comply with the section cited above in that S1 did not have a Health Screen on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility to submit to CCL completed Health Screen for S1 by plan of correction due date. Photographic proof is acceptable.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 09/24/2024 12:21 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/24/2024 at 12:03 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: LAUGHLIN COUNTRY HOME
FACILITY NUMBER: 490111817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 09/24/2024 12:21 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/24/2024 at 12:05 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: LAUGHLIN COUNTRY HOME
FACILITY NUMBER: 490111817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
Page: 11 of 14