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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800668
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:36:27 PM

Document Has Been Signed on 09/30/2024 01:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SARAH'S ADULT RESIDENTIAL CAREFACILITY NUMBER:
496800668
ADMINISTRATOR/
DIRECTOR:		GREGORI, LINDSEYFACILITY TYPE:
735
ADDRESS:3030 TERRA LINDA DRIVETELEPHONE:
(707) 527-8990
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 2DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Alma Gonzalez Fragoso-CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso is conducting an Required-1 Year inspection, on 9/30/24 at approximately 9:15am, and met with caregiver Alma Gonzalez. Administrator Lindsey Gregorio arrived at the facility to meet with the LPA.

There are two (2) clients residing in the home; Clients were at day program during the inspection. Facility has an approved fire clearance for six (6) ambulatory. The facility will be using the four client rooms as private bedrooms. The facility does have a required infection control plan.

The LPA reviewed two (2) resident files. Files had required documents. Client P&I funds were maintained as required, and was observed to not mixed with facility petty cash and/or any other funds.
The LPA reviewed five(5) staff files. All staff have required criminal record clearance. All staff have required training. All staff have first aid and cpr certification.

Facility had a sufficient food supply. Sufficient cleaners/disinfectants, paper products, hygiene products, and linens. Facility had a sufficient supply of furnishings for client use. The facility was observed to be at a comfortable temperature. Sufficient lighting in hallways, bathrooms, resident rooms, and common areas. Hot water was checked at 114.6 degrees Fahrenheit, which is within regulation.

LPA is requesting the following documents be updated and submitted by 10/30/2024:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
Infection Control Plan (review& update if needed-if updated submit a copy-if no changes-
send last page of signed review)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Surety bond-send sufficient coverage per form
Resident Roster
Copy of current Administrator Certificate
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668
VISIT DATE: 09/30/2024
NARRATIVE
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The following deficiencies were observed and will be cited, see LIC809D.
LPA observed broken furniture, treadmill, miscellaneous items, including in the garage that need to be removed from the facility. The LPA observed a floor vent with a large gap with no slats in place. LPA observed a kitchen light structure, and the overhead fan/light of the stove, with non-working bulbs, and torn light panel covers. LPA obtained photos. Deficiency cited, Buildings and Grounds 80087(a)- The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. LPA observed screens in the slider door in the living room, and screens in vacant client rooms that need to be repaired/replaced. LPA obtained photos. This deficiency will be cited, 80088(b)Furniture, Fixtures, Equipment, and Supplies-All window screens shall be in good repair and be free of insects, dirt and other debris.

LPA observed a client's window curtains on the slider were hanging on the outside of the room, where they can be opened up by anyone; Client's personal privacy is at risk with the curtains on the outside. Client's room had no curtains/covering on the window to ensure client has personal privacy when wanted. LPA obtained photos. Deficiency cited, Personal Rights 80072(a)(1)(2) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

Per record reviews, facility lacked a required emergency disaster plan. This must be completed and added to the facility's plan of operation. HSC1565(a)(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following listed in HSC 1565.

Deficiencies cited from the California Code of Regulations, Title 22,


Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Administrator, Lindsey Gregorio.
Appeal rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/30/2024 01:36 PM - It Cannot Be Edited


Created By: Dina Alviso On 09/30/2024 at 12:51 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds 80087(a)- The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed broken furniture, treadmill, miscellaneous items, including in the garage that need to be removed from the facility. The LPA observed a floor vent with a large gap with no slats in place. LPA observed a kitchen light structure, and the overhead fan/light of the stove, with non-working bulbs, and torn light panel covers. LPA obtained photos, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee/Administrator to ensure the facility is clean, safe, and sanitary at all times. Ensure all items listed are removed from facility and items needing to be repaired are completed; Ensure all items are completed by 10/21/24, submit how it was corrected and submit pictures. POC due 10/21/24.
Type B
Section Cited
CCR
80088(b)
80088(b)Furniture, Fixtures, Equipment, and Supplies-All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed screens on the slider door in the living room, and screens in vacant client rooms that need to be repaired/replaced, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Licensee/Administrator to ensure all the screens listed in the deficiency are repaired and/or replaced as needed. Submit how the deficiency was corrected and submit photos. POC due 10/14/2024.
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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/30/2024 01:36 PM - It Cannot Be Edited


Created By: Dina Alviso On 09/30/2024 at 01:04 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: SARAH'S ADULT RESIDENTIAL CARE
FACILITY NUMBER: 496800668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(1)(2
80072(a)(1)(2) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed a client's window curtains on the slider were hanging on the outside of the room, where they can be opened up by anyone; Client's personal privacy is at risk with the curtains on the outside. Client's room had no curtains/covering on the window to ensure client has personal privacy when wanted. LPA obtained photos, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee/Administrator to ensure the client has window coverings on their window and slider door and/or privacy film (not able to see in from the outside)as discussed with Administrator, helping to ensure the right to client's personal privacy. POC due 10/21/2024.
Type B
Section Cited
HSC
1565(a)
HSC1565(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following listed in HSC 1565.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per record reviews, facility lacked a required emergency disaster plan. This must be completed and added to the facility's plan of operation, the licensee did not comply with the section cited, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee/Administrator to ensure that the emergency disaster plan is completed as required, submitted, and all staff trained regarding emergency disaster plan. Ensure the plan addressed all required boxes. Submit copy of emergency disaster plan by 10/21/2024.
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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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