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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 04/24/2024
Date Signed: 04/25/2024 08:37:59 AM

Document Has Been Signed on 04/25/2024 08:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WIMBLEDON HOUSE #1FACILITY NUMBER:
496800621
ADMINISTRATOR/
DIRECTOR:		BARONI, PIA E.FACILITY TYPE:
735
ADDRESS:629 WEST 3RD STREETTELEPHONE:
7075277628
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 3DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Pia Loius, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Julie Florio and Stefanie Mutialu arrived unannounced, to conduct a required 1-year annual inspection and were greeted by Ruby Mendoza, Behavioral Therapist with Redwood Integrative Services. Licensee/Administrator, Pia Louis was getting ready and came to greet LPAs shortly after. At approximately 3:45PM, Licensing Program Manager Bethany Moellers arrived at facility for observation.

LPAs initiated a tour of the facility around 9:50am and observed the following: Facility is a one story home and was a comfortable temperature. LPAs observed the home not kept clean and orderly, as evidenced by screens broken or missing, debris scattered in yard and in house, feces observed on one toilet, urine smell, uncovered food left on counter. Passageways were free from obstructions. Water temperatures measured at 106, 107, and 109 degrees F, which is within allowable range of 105 to 120 degrees F. Cabinets containing cleaning supplies and other items that could pose a risk were unlocked. LPAs informed licensee that all cleaning supplies and chemicals which pose a potential risk to client's in care shall remain locked while unattended. There was ample space for personal hygiene products and ample utensils, dishes, and cook ware. LPAs observed insufficient clean linens available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Facility has at least two days of perishable food, but does not have one week of non-perishable foods. LPAs observed cooked foods left out and not stored properly and with flys present. LPAs observed non-perishable foods not sealed and stored properly. Medications were centrally stored and locked. LPAs observed medication on the floor in common area. Licensee immediately picked up and disposed of the medication. There is outdoor space for activities that was inspected and found to have personal belongings, clothes, and boxes scattered near exits, as well as chemicals and power tools accessible to clients in care.

Fire extinguisher was last serviced July 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular disaster drills and the most recent drill was conducted January 2024. LPA advised to ensure flashlights are accessible. Licensee was advised to obtain and post CCL information poster in a conspicuous place in the facility.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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 15
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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621
VISIT DATE: 04/24/2024
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Continued from LIC809...

At approximately 10:45am six staff files and three client files were reviewed. Staff have required First Aid certificates and required annual and medication administration training. Three of six staff files reviewed did not have health screening and TB results in them. LPAs observed 1 client with PRN inhaler, Licensee agrees to ensure staff have training assisting client with inhaler. Medications were centrally stored and reviewed. Licensee does not have any sort of medication administration logs or centrally stored medication destruction log which is not within regulation. LPAs were informed that clients manage their own money and accounts. Facility does have surety bond if needed. LPAs were greeted by Ruby Mendoza, Behavioral Therapist with Redwood Integrative Services. LPAs advised due to caregiver providing care and supervision in licensed setting to ensure all staff are fingerprint cleared and associated to the facility.

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
LIC503 - Staff Health Screening
Proof of current Administrator Certificate

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Licensee and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 15
Document Has Been Signed on 04/25/2024 08:37 AM - It Cannot Be Edited


Created By: Julie Florio On 04/24/2024 at 03:22 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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as evidenced by LPAs observation of dinner and breakfast meals left out on the counter and uncovered and unlabeled foods which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Licensee to submit self-certification that all food is appropriately labeled and stored by POC dute of 4/25/2024. LIcensee to submit proof of an all staff training regarding proper food safety, labeling and storage by 05/06/2024.
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out 2 client records reviewed. LIcensee does not have a medication administration or destruction log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Licensee to submit self-certification that all client medications are being logged in a medication administration and destruction log by POC dute of 4/25/2024. LIcensee to submit proof of a medication administration and destruction log by 05/06/2024.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 08:37 AM - It Cannot Be Edited


Created By: Julie Florio On 04/24/2024 at 03:34 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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as evidenced by LPAs observation of cleaning supplies, chemicals, and other toxins accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Licensee to submit self-certification that all toxins are secured and inaccessible to clients by POC dute of 4/25/2024.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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