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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 08/05/2024
Date Signed: 08/05/2024 01:58:28 PM

Document Has Been Signed on 08/05/2024 01:58 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:WIMBLEDON HOUSE #1FACILITY NUMBER:
496800621
ADMINISTRATOR/
DIRECTOR:		BARONI, PIA E.FACILITY TYPE:
735
ADDRESS:629 WEST 3RD STREETTELEPHONE:
(707) 527-7628
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 4DATE:
08/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Pia Baroni-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alviso and Loera are conducteing a case management visit, on 8/5/24 at approximately 8:40am, and met with Administrator/Licensee Pia Baroni. Caregiver Justina Macias was working on shift upon LPAs arrival. One to one staff for client (C1) arrived during the LPAs inspection. Three clients (C1, C2, C3,) were home during the LPAs inspection.

This case management is being conducted to address some deficiencies that were identified during the complaint inspection of earlier today, see LIC9099.

During the LPAs arrival to the facility it was observed that there were two wrap around combination locks on the driveway's chain link fence/gate, which is a fire code violation. LPAs observed the Administrator remove a wood bar that was in the slider doors track keeping the door from opening unless removed, this is a fire code violation. This deficiency will be cited, 80020(a) Fire Clearance- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, see LIC809D.

Licensee/Administrator failed to report client AWOL of 7/28/24; On 7/28/24 the client AWOL the facility, staff stated the client was supposed to be sleeping. C1 was picked up by CHP, wandering the Highway, and taken to the emergency room for assessment. Facility staff were notified and picked up C1 at the hospital/ER on 7/29 approximately sometime after 1:00pm. This deficiency will be cited, 80061(b)(1)(E) Reporting Requirements- Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report Any unusual incident or client absence which threatens the physical or emotional health or safety of any client, see LIC809D.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency (s) on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Appeal Rights Given to the Administrator
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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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Document Has Been Signed on 08/05/2024 01:58 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/05/2024 at 12:53 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: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2024
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement has not been met as evidenced by:


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Licensee/Administrator to ensure the wrap around combination locks and/or any locking device is not put on the driveway gate/fence at any time. Remove the bar and don't put the wooden bar in the slider door track or any other device in it at any time.
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LPAs observations during inspection. it was observed that there were two wrap around combination locks on the driveway's chain link fence/gate, which is a fire code violation. LPAs observed the Administrator remove a wood bar that was in the slider doors track keeping the door from opening, This is a fire code violation. Immediate Civil Penalty will be assessed-
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The fire clearance must be maintained per fire department approval at all times. Submit plan of maintaining compliance with this regulation by POC due date of 8/6/24.
Type B
08/12/2024
Section Cited
CCR80061(b)(1)(E)

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80061(b)(1)(E) Reporting Requirements- Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be
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Licensee/Administrator to ensure all required reporting is completed; Submit incident report on C1 of 7/28/24 AWOL. POC due 8/12/2024.
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submitted to the licensing agency within seven days following the occurrence of such event. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
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