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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:36:10 PM

Document Has Been Signed on 11/12/2021 02:36 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:WIMBLEDON HOUSE #1FACILITY NUMBER:
496800621
ADMINISTRATOR:BARONI, PIA E.FACILITY TYPE:
735
ADDRESS:629 WEST 3RD STREETTELEPHONE:
(707) 527-7628
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 4DATE:
11/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Pia Baroni (Licensee)TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management inspection and met with Licensee, Pia Baroni. LPA conducted risk assessment call with Licensee prior to the visit. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

LPA is following up on a self incident report submitted to CCL on 11/10/21 by Licensee, Pia Baroni who informed that client (C1) who on November 2, 2021 woke up very weak, staff and Licensee had to help client in and out of shower, C1's hair was falling out in chunks and refused to eat. Licensee contacted Kaiser advice nurse and was instructed to bring C1 immediately to Kaiser emergency room. Blood work was performed to C1 and their hemoglobin levels were low that leaded to a blood transfusion. Responsible parties were notified.

During today's visit LPA reviewed C1's discharge documents who was treated in the hospital for weakness due to microcytic anemia and found to have adenocarcinoma cecum, new medications were prescribed and follow up appointment was scheduled for November 16, 2021 with C1's Physician to discuss their options including surgery.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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