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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:11:16 PM

Document Has Been Signed on 05/13/2022 12:11 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:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Megan Lawrence-Ferreira (Administrator)TIME COMPLETED:
12:26 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
Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Megan Lawrence-Ferreira. Administrator informed LPA that they have reviewed PIN 22-07, 22-09 and PIN 22-13.

LPA arrived at the facility and have their temperature checked and logged into a sign-in sheet. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least two times a day. Facility is allowing indoor visitations and has antigen tests available to use for visitors. Facility is able to accommodate a single room for each client that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and has been N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has 100% vaccination rate and boosters for all staff and clients. Three out of three clients do attend to day program two days per week in average and the facility also provides activities. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has submitted their Covid Mitigation Plan and approved on 5/28/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.

Administrator provided updated copies of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E) and surety bond.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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: 05/13/2022
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
26
27
28
29
30
31
32
Continued from LIC809...

During today's visit LPA followed up on an incident report submitted to CCL along with a SOC341 dated 4/15/22. Per incident report, on 4/14/22 approximate 1:00pm client C1 was attacked by an unknown male at the Santa Rosa Transit mall. The male perpetrator chased C1 through the Transit Mall yelling “you killed my son”. C1 was tackled by the individual and was able to fight him off and run away. C1 found a safe area in the Santa Rosa Town Square and called their father. C1 and their father contacted the police. The individual who attacked C1 was placed under arrest by the Santa Rosa Police Department. C1’s father drove them home where they received first aid by the facility nurse, C1 sustained bruising and scrape on their right arm. Facility staff monitored C1 throughout the rest of the day. C1 was scared and reported difficulty sleeping, staff offered them support and facility nurse reviewed coping skills.

Facility nurse recommended that C1 follow up with their Physician to conduct an x-ray of their wrist and possibly a Physician's order for over the counter PRN pain medications. Administrator will request a copy of the police report and submit to CCL and NBRC when available. As a preventive plan the facility had a consult with NBRC Service Coordinator regarding additional options for community engagement, increased Day Program days and/or employment. Staff will identify alternative routes to go home so C1 does not have to walk through the Transit Mall. Also; staff will continue to track C1's outings and offer coaching in community safety. Per Administrator, NBRC Service Coordinator will conduct a visit this coming Tuesday, May 17 2022 to discuss possible options for C1 to prevent that this type of incidents happen again. Staff drove with C1 around the area, showed them a different route to avoid the Transit Mall area to come home.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2