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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 09/09/2022
Date Signed: 09/12/2022 11:50:54 AM

Document Has Been Signed on 09/12/2022 11:50 AM - 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: DATE:
09/09/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sarah Lawrence (Licensee)TIME COMPLETED:
10:30 AM
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A Non-Compliance Conference was conducted today in the Santa Rosa Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were Licensing Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, Licensee, Sarah Lawrence and Administrator, Megan Lawrence-Ferreira.


This Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency regarding to the operation of this facility including but not limited to: Complaint investigation that has been substantiated for Resident sustained injuries while in care and timely medical attention. Other concerns that have been observed during a post-licensing visit are:

- Responsibility for Providing Care and Supervision facility staff failed to notice unstageable pressure injury and any bruises which resulted in C1 sustaining unexplained injuries while in care.

- Timely Medical Attention: Facility failed to seek timely medical attention.

- Personnel Requirements: Facility didn’t provide necessary staff to meet C1’s needs including noticing bruises after witnessed fall on 1/27/22 resulting in C1’s hospitalization.

The Regional Office will re-review progress made on Non-Compliance Plan of 2 years.



Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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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: 09/09/2022
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Continued from LIC809...

CCL has provided copies of the following Regulations: Title 22 Regulations #80078 Responsibility for Providing Care & Supervision; #80075 Health Related Services; #80065 Personnel Requirements.

Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:


1. Responsibility for Providing Care and Supervision facility staff failed to notice unstageable pressure injury and any bruises which resulted in C1 sustaining unexplained injuries while in care. Facility has submitted a plan of correction on August 31, 2022.

2. Timely Medical Attention: Facility will ensure to seek timely medical attention for clients in care. Facility has submitted a plan of correction on August 31, 2022.

3. Personnel Requirements: Facility will provide necessary staff to meet client’s physical, social, emotional, safety and health care needs. Facility has submitted a plan of correction on August 31, 2022.

Facility agreed to provide updates of the following by 9/16/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500).



The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20201207072042.

There were no deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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