<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 08/26/2021
Date Signed: 08/26/2021 02:34:21 PM

Document Has Been Signed on 08/26/2021 02:34 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:
08/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Lamon Jr Lawrence (staff)TIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Cuadra arrived unannounced to conduct a case management inspection and met with staff, Lamon Jr Lawrence. Administrator, Megan Lawrence-Ferreira was available by phone and gave authorization to staff to sign the report. 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/staff observed 2 out of 3 staff not wearing a mask. [80072(a)(2)]

LPA is following up on an incident related to an incident report and SOC341 received on 8/23/21 from Administrator, Megan Lawrence for suspected abuse occurred on 8/18/21 to client (C1) by an unidentified male inside of the restroom at Food Maxx. C1 went to the store with support staff from Day Program. The man yelled at C1 to “flush the toilet”. C1 replied “I did”. The man then followed C1 outside of the store, approached C1 and slapped across the face of C1. Support staff notified Administrator about the incident.

Administrator, staff and housemates offered support to C1. Administrator assessed C1 for safety and possible wounds or bruising. C1 reported that there was no pain and accepted a cold ice pack to hold on their eye/cheek area for 10 minutes. No emergency room intervention was deemed necessary upon completion of an immediate risk assessment. The incident was documented, and responsible parties were notified. As a preventive plan it was agreed by C1 to limit communication with strangers when in the community.

During today’s visit LPA attempted to review C1’s file including Physician’s report that indicated that C1 is allowed to be out in the community without assistance. LPA was able to review other documents related to the SOC341- Suspected Elder/Dependent Abuse. However, C1's physician's report was not available at the facility. [80070 (d)]

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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
Document Has Been Signed on 08/26/2021 02:34 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/26/2021 at 01:57 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SARAH'S BANCROFT DRIVE ADULT HOME
FACILITY NUMBER: 496800869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited
CCR
80072(a)(2)

1
2
3
4
5
6
7
80072 Personal Rights (a)... residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement has not been met as evidence by:
1
2
3
4
5
6
7
Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for mask requirement for all staff to LPA by close of business 8/27/2021.
8
9
10
11
12
13
14
Based on LPAs observation and interview. Licensee did not ensure S1 and S2 was wearing a mask as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
8
9
10
11
12
13
14
Type B
09/10/2021
Section Cited
CCR80070(d)

1
2
3
4
5
6
7
80070 Client Records (d) All client records shall be available to the licensing agency to inspect, audit, & copy upon demand during normal business hours...This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee agrees to keep a copy of client files at the facility site. Licensee will submit a self certification LIC 9098 that a copy of client (C1) physician's report is at the facility site to CCL by POC due date of 9/10/2021.
8
9
10
11
12
13
14
Based on interview Licensee did not ensure that client (C1) physician's report (LIC602) were available at the facility site which poses a potential risk to clients in care.
8
9
10
11
12
13
14
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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2