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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:32:48 PM

Document Has Been Signed on 10/13/2022 02:32 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: 4DATE:
10/13/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Megan Lawrence-Ferreira (Administrator)TIME COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Administrator Megan Lawrence-Ferreira. Licensee Sarah Lawrence arrived later. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 9/9/22:

80078 (a) Responsibility for Providing Care and Supervision: facility staff failed to notice unstageable pressure injury and any bruises which resulted in client sustaining unexplained injuries while in care. During this visit, LPA/Administrator reviewed staff schedule for the month of September 2022 and LIC500. The facility has 1 staff for morning shift 6am-10am, 2 staff for afternoon shift 2pm-10pm and 1 staff for night shift 10pm-6am. Also, LPA/Administrator observed daily care log starting on 9/27/22 for each resident.

80075 (a) Health Related Services: facility staff failed to seek timely medical attention. LPA reviewed resident’s records and self-incident reports and it appears that staff had been responding timely to medical emergencies.

80065 (a) Personnel Requirements: Facility will provide necessary staff to meet client’s physical, social, emotional, safety and health care needs. LPA reviewed staff training records and most of staff (S1, S2, S3 and S4) has received DSP Year 1 and 2 annual training including special incident reporting, valid CPR/1st aid and assessing for changes in residents functioning, injuries and crisis intervention. Facility is in the process to associate a Registered Nurse to provide training to staff.

No deficiencies cited during today's inspections. Exit interview was conducted with Administrator a copy of this report was provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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