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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:20:45 PM

Document Has Been Signed on 09/16/2021 02:20 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:SARAH'S BANCROFT DRIVE ADULT HOMEFACILITY NUMBER:
496800869
ADMINISTRATOR:LAWRENCE-FERREIRA, MEGANFACILITY TYPE:
735
ADDRESS:1842 BANCROFT DRIVETELEPHONE:
(707) 823-9365
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Sarah Lawrence (Licensee) and Megan Lawrence (Administrator)TIME COMPLETED:
02:35 PM
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LPA Cuadra arrived unannounced to conduct a case management inspection and met with Licensee, Sarah Lawrence and Administrator, Megan Lawrence-Ferreira. LPA conducted risk assessment call with Administrator 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 an incident received on 9/3/21 from Administrator regarding client (C1). On 9/1/21 staff alerted Administrator that C1's right upper forearm appeared slightly swollen. C1 was offered an ice pack to reduce swelling. Administrator assessed C1's condition and scheduled an appointment with their Physician. On 9/2/21 staff alerted Administrator that C1's condition got worsen and a large purple bruise was noticed on their upper right arm. Administrator scheduled a doctor's appointment for the same day and provided pictures. Doctor ordered a X-ray and an ultrasound following the appointment. On 9/3/21 Administrator received a call from C1's doctor stating that C1 should not been allowed to return home and should went to ER for treatment due to a "Proximal Humerus fracture" of their right arm due to an un-witnessed fall. C1 was referred to Kaiser Orthopedic Department, new medications were prescribed as PRN as needed for pain and to have their arm placed in a sling. As a preventive measure Administrator requested supplemental staffing hours to cover the night hours and ensure C1 is provided with supervision to meet their needs. Responsible parties were notified, NBRC and CCL as well were notified.

During today’s visit LPA reviewed C1’s file including Physician’s report that indicated C1's plan of care for next 2 weeks after injury, 6 weeks after injury and 10-12 weeks after injury. The treatment does not include surgery.
LPA also confirmed that prior deficiencies were corrected [80072(a)(2)] LPA/staff observed all staff wearing a mask and [80070 (d)] Client's files including physician's report were available at the facility.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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