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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800869
Report Date: 06/09/2023
Date Signed: 06/09/2023 02:26:48 PM

Document Has Been Signed on 06/09/2023 02:26 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:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Megan Lawrence-Ferreira (Administrator)TIME COMPLETED:
02:41 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Legal/Non-compliance, and Annual Required inspection and met with Administrator Megan Lawrence-Ferreira. At the time of visit, clients were attending to Day Program except one client who was at home.

Upon arrival, LPA confirmed with Administrator that they are following current Covid19 and masks guidance. LPA/Administrator initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathroom read at 107.4 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet in the garage. Medications are centrally stored in locked closet. Fire extinguishers were last inspected March 2023. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 6/6/23. Facility does have a current activity calendar and menu. Required postings were observed. First aid kit was fully stocked. Cash resources and documentation were reviewed.

LPA initiated a file review at 1:00 pm. Four client and six staff files were reviewed. Clients records have updated care plans on file. First aid certificates for staff are current. Administrator Certificate for Megan Lawrence-Ferreira 604663075 expires 1/19/2024. Medications and medication records were reviewed.

Continues on LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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: 06/09/2023
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Continued from LIC809...


During this visit, LPA also followed up on items that were concerning and ensure compliance with Non-Compliance Conference dated 9/9/22:

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 attention to medical emergencies.

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 June 2023 and LIC500 Personnel Report. The facility has 1 staff for morning shift 6:00am-2:00pm, 1 staff for afternoon shift 2:00pm-10:00pm and 1 staff for night shift 10:00pm-6:00am. Also, LPA/Administrator observed daily care log for the month of June 2023 for residents in care.

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 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 has a Registered Nurse that provides monthly training to all staff and helps with the resident's care plans updates.

LPA obtained updates of the following documents: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 (cash affidavit for clients) and LIC610D - Emergency Disaster Plan.



No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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