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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 04/19/2024
Date Signed: 04/19/2024 02:54:11 PM

Document Has Been Signed on 04/19/2024 02:54 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:SARAH'S BANCROFT DRIVE ADULT HOMEFACILITY NUMBER:
496800869
ADMINISTRATOR/
DIRECTOR:		LAWRENCE-FERREIRA, MEGANFACILITY TYPE:
735
ADDRESS:1842 BANCROFT DRIVETELEPHONE:
(707) 823-9365
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Megan Lawrence-Ferreira (Administrator)TIME VISIT/
INSPECTION COMPLETED:
03:09 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Administrator Megan Lawrence-Ferreira. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 9/9/22:

80078 (a) Responsibility for Providing Care and Supervision: facility staff failed to notice unstageable pressure injury and any bruises which resulted in client sustaining unexplained injuries while in care. During today's visit, LPA/Administrator reviewed staff schedule for the month of April, 2024 and LIC500 Personnel Report, which includes staffing as follow: One staff in the morning shift 6:00am-10:00am during weekdays and 6:00am-2:00pm schedule on weekends, one staff for afternoon shift between 2:00pm - 10:00pm and one staff for night shift 10:00pm-6:00am, no live-in staff. Also, LPA/Administrator reviewed daily care log for the month of March and April, 2024 for each resident which appears to be in compliance.

80075 (a) Health Related Services: facility staff failed to seek timely medical attention.LPA/Administrator reviewed resident’s records and recent self-incident reports, where it seems like staff had been responding timely to resident's medical emergencies including doctor and dental appointments.

80065 (a) Personnel Requirements: Facility will provide necessary staff to meet client’s physical, social, emotional, safety and health care needs. LPA reviewed staff training records, the facility staff has received required annual training including special incident reporting, valid CPR/1st aid and assessing for changes in residents functioning, injuries and crisis intervention. Facility hired a Registered Nurse (RN) that provides quarterly training to all staff and helps with the resident's care plans updates to include any changes of condition observed. The last visit conducted by RN was on 2/23/2024.

No deficiencies cited during today's inspections. Exit interview was conducted with Administrator a copy of this report was provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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