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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800621
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:42:11 PM

Document Has Been Signed on 10/05/2022 02:42 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: 2DATE:
10/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Sheena Blackwell (staff)TIME COMPLETED:
02:57 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management inspection and met with staff Sheena Blackwell. Licensee, Pia Baroni was not able to come to the facility but was available by phone and gave authorization to staff to sign the report.

LPA is following up on a self incident report submitted to CCL on 9/16/22 by Licensee, Pia Baroni who informed that client (C1) who on 9/13/22 was walking in the kitchen when experienced a leg spasm and fell. The fall resulted in an ankle injury and fibula fracture. C1 was given no restrictions by their doctor and was given a walking boot and a prescription for Naproxen to take 2x/day. The witnessed fall by Licensee and staff. C1 was placed in bed and ice elevate the affected area, an appointment was made to be seen at urgent care the next day. The plan is to increase C1's exercise level when tolerable to prevent spasms from causing them similar injuries. Responsible parties were notified.

During today's visit LPA reviewed C1's discharge documents who was treated in the hospital for ankle injury and fibula (lower leg bone) fracture, no new medications were prescribed and follow up appointment was not needed. Their responsible party still wanted to schedule a follow up appointment this month for their Physician to evaluate. LPA also observed C1 and no concerns were raised at this time.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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