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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:05:16 PM

Document Has Been Signed on 08/22/2024 12:05 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:
08/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Megan Lawrence-Ferreira (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On August 22, 2024, Licensing Program Analyst (LPA) Cuadra met with Administrator, Megan Lawrence-Ferreira for a Case Management at the facility to follow up on substantiated complaint allegations; complaint number 21-AS-20220202091317.

On August 30, 2022, the Department concluded an investigation which alleged that a client sustained injuries while in care and facility failed to seek medical attention in a timely manner.

The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “80075(a)” facility failed to seek medical attention in a timely manner when a client (C1) was observed to have a change of condition requiring medical attention. Additional citations were issued under California Code of Regulations (CCR) Title 22, § “80078(a)” for staff failing to notice bruises and an unstageable pressure injury.

At the time of the complaint visit on August 30, 2022, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1548(f)(1)(A).

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Penal Code section 243 defines serious bodily injury as a serious impairment of physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of function of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.

Continue LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800869
VISIT DATE: 08/22/2024
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Continued from LIC809...

This is evidenced by the facility’s lack of proper care and supervision and delay in seeking timely medical attention requiring C1 to be hospitalized. Based on the information obtained by the Department during the investigation, C1 sustained an unexplained injury, had complaints of pain on January 26, 2022, and the facility staff failed to seek timely medical attention until January 31, 2022.

Today, August 22, 2024, the Department is issuing a civil penalty per Health and Safety Code §1548(f)(1)(A) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 as previously issued on August 30, 2022, the amount of the civil penalty issued today will be $9,500.



Exit interview conducted with Administrator. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2