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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800004
Report Date: 10/18/2021
Date Signed: 10/18/2021 02:48:13 PM

Document Has Been Signed on 10/18/2021 02:48 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:B&J STEPHANIEFACILITY NUMBER:
496800004
ADMINISTRATOR:WU, BINGFACILITY TYPE:
735
ADDRESS:2430 SANTA CRUZ COURTTELEPHONE:
(707) 477-5416
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 4CENSUS: 4DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Dongmei Graves (staff)TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection – 1 yr. Infection Control inspection met with staff, Dongmei Graves. LPA conducted a Risk Assessment call with Licensee prior to the visit and was informed that he was not able to come to the facility due to personal issues. However, Licensee gave authorization to staff to sign the report.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that staff were wearing masks during this visit. At approximately 1:20pm LPA observed and verified that staff (S1 and S2) that were present and providing care at the facility were not associated to the facility Personal Report/Roster in Guardian. Licensee stated that S1 and S2 worked at his other facility. LPA confirmed that S1 and S2 were associated to other facility. Licensee agreed to contact CCL office to associate both staff to this facility. ***Civil penalties are being assessed in the amount of $250 for repeated violation of allowing a person to work, reside or volunteer in the facility without a fingerprint clearance or exemption.

LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Hand sanitizer are located through the facility. Facility has a bathroom that is kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least once a day. Facility has designated an outdoor area for visitation. Facility staff have been trained on PPE protocols, but have not yet been N-95 fit tested. Staff and residents are being monitored daily and facility does document daily screening results in a binder. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents. Day program staff come to the facility to take them out for activities once a week on average. Facility has games and other activities for client use during off days. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. Facility has submitted their Covid Mitigation Plan and was approved on 3/12/21. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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Document Has Been Signed on 10/18/2021 02:48 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/18/2021 at 02:27 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: B&J STEPHANIE
FACILITY NUMBER: 496800004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observation, interview and record review, the licensee did not comply with the section cited above in two staff (S1 and S2) were not associated to the facility prior to provide care and supervision to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2021
Plan of Correction
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Licensee agreed to send in fingerprint transfer request to Community Care Licensing (CCL) for both staff (S1 and S2) to associate them to the facility. Licensee will conduct an audit of all staff working on both facility and will associate any staff that is currently not associated to the facility and is working providing care and supervision to clients in care. Facility to submit required forms to CCL by POC due date 10/19/2021. **Civil Penalty assessed in the total amount of $500.00 for repeated violation during visit on 7/1/2021.
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: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021


LIC809 (FAS) - (06/04)
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