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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:48:25 PM

Document Has Been Signed on 02/01/2022 03:48 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 3DATE:
02/01/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Pia Baroni (Licensee)TIME COMPLETED:
03:45 PM
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An informal meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, Licensee Pia Baroni and Sextant Consultant Lance Parker.

The purpose of the informal office meeting was to discuss areas of non-compliance and observed and ongoing Community Care Licensing concerns of the operation of Wimbledon House #1 #496800621.

Items addressed in today's meeting include but are not limited to patterns and trends in the areas below:
- Lack of staffing to meet resident’s care needs.
- Staff vaccination status, exemptions and weekly testing.
- Hospice care requirements.
- Staff training.
- Licensee and involvement in facility operation

Documents requested during informal meeting to be submitted to CCL by Monday, February 7, 2022:

-Licensee will submit an updated LIC500 indicating 24/7 schedules with specific staff coverage.
-Licensee will submit staff medical or religious exemptions for staff and clients that refuses to be vaccinated for Covid19.
-Licensee agreed to submit staff training records for client receiving hospice services.
-Licensee will submit staff training records within the last 12 months for all staff including medication training.
-Licensee to develop policy identifying staff member(s) responsible for ensuring all medications are followed as physician’s directions including entering medications into the Centrally Stored Medication and Destruction Log.
Failure to submit above documentation may result in the Department seeking further action.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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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