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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:11:11 PM

Document Has Been Signed on 08/30/2022 02:11 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:LAWRENCE-FERREIRA, MEGANFACILITY TYPE:
735
ADDRESS:1842 BANCROFT DRIVETELEPHONE:
(707) 823-9365
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 3DATE:
08/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Sarah Lawrence (Licensee)TIME COMPLETED:
02:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation #21-AS-20220202091317 and met with Licensee, Sarah Lawrence and Administrator, Megan Lawrence-Ferreira.

LPA learned through records review that supplemental staffing request dated 6/11/21 was approved by North Bay Regional Center indicating that C1 required one on one supervision to provide awake overnight supervision due to behavior challenges, supplemental staffing was approved for 15 hours per day effective 1/1/22 to 1/31/23, but investigation revealed that facility only provided overnight supervision for two to three nights per week.

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: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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Document Has Been Signed on 08/30/2022 02:11 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/30/2022 at 01:38 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 BANCROFT DRIVE ADULT HOME
FACILITY NUMBER: 496800869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2022
Section Cited
CCR
80065(a)

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80065 (a) Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
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Administrator/Licensee agreed to have sufficient staff to supervise and provide care to clients at all times. Facility to submit CCLD a plan on how to ensure that facility will have enough staff at all shifts and that clients will have their needs met by POC due date.
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Based on interviews and records review facility failed to provide necessary staff to meet C1’s needs including noticing bruises after witnessed fall on 1/27/22 resulting in C1’s hospitalization which poses an immediate risk to the health and safety of clients in care.
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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: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
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