496800937-1-9-2025-21-AS-MCUA-DCRVQB-20250109153803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800937
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:38:17 PM

Document Has Been Signed on 01/09/2025 03:38 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 SENIOR RESIDENTIAL CARE		FACILITY NUMBER:	496800937
ADMINISTRATOR/ DIRECTOR:	ARAYA, SARAH		FACILITY TYPE:	740
ADDRESS:	1601 CLOVER DRIVE		TELEPHONE:	(707) 542-4082
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:43 PM
MET WITH:	Sarah Araya (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	03:52 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 Analysts (LPAs), Cuadra and Frank, arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Sarah Araya. Clients were at day program at the time of visit. Annual fees current. Contact information reviewed. Required postings were observed. LPA/Administrator initiated a tour of the facility at 2:00 pm and observed the following: Facility was a comfortable temperature and pathways were free from obstructions. However, during the tour of the facility there were some trip hazards observed in the backyard. LPAs had a conversation with Administrator regarding the importance to keep area of potential hazard for residents with poor balance or eyesight challenges well maintained. Fire extinguishers were last inspected January 8, 2025. Smoke detectors and the carbon monoxide detector were tested and operational during inspection. Last Disaster drill was conducted on October 18, 2024. P&I and cash resources were reviewed. First aid kit was missing the tweezers (technical violation issued) Resident bathroom has required bath mat and grab bars. Water temperature in resident bathroom measured at 113.5, 111.8 and 115.6 degrees F which is within the range allowed by regulation of 105 to 120 degrees F. Toxins are located under the sink in the kitchen, garage and bathroom and all were locked. At least two days of perishable and seven days of non-perishable foods were available. Continued on LIC809C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Marisol Cuadra	TELEPHONE: (707) 588-5078
	DATE: 01/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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 01/09/2025 03:38 PM - It Cannot Be Edited

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 SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 496800937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Administrator's observation and interview, the licensee did not comply with the section cited above by having the medication lock key hanging on the wall accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	Administrator removed the key during the visit. Administrator will obtain a lock box and will submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance by POC due date 1/10/25 to CCL to clear the citation.

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Administrator's observation, interview and record review, the licensee did not comply with the section cited above in one out of five resident's (R1) medication, Atorvastatin whole tablet was found loose in the medication container which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2025
	Plan of Correction
1 2 3 4	Facility to conduct in-service training for all staff reviewing that handles medications to ensure their understanding about medication management and loose medication are not allowed at any time. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 1/10/2025

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Marisol Cuadra	TELEPHONE: (707) 588-5078
	DATE: 01/09/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2025 03:38 PM - It Cannot Be Edited

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 SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 496800937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Administrator's observation and interview, the licensee did not comply with the section cited above by not ensuring that areas of potential hazard are well maintained for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	Administrator agrees to provide a plan of action to address the areas of concern to CCLD. In addition, Administrator will submit pictures of correction of the areas of concerns located in the backyard by POC due date of 1/17/24 to clear the citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Marisol Cuadra	TELEPHONE: (707) 588-5078
	DATE: 01/09/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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 SENIOR RESIDENTIAL CARE	FACILITY NUMBER: 496800937
	VISIT DATE: 01/09/2025

NARRATIVE

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Continued from LIC809...

At approximate at 2:15pm, during the tour of the facility, LPA/Administrator observed that medications were centrally stored and locked, but the key is kept hanging on the wall accessible to residents in care. Administrator immediately removed the key and will get a lock box.

At approximate at 2:20pm, A spot check of medications revealed a loose white tablet "Atorvastatin" was found in the container of resident's (R1) medication. Administrator will review medication and their records and will conduct a staff training.

LPAs initiated file review at 2:30 pm. Four resident files including medical assessment and care plans. Two staff files were reviewed. Staff have required CPR/1st aid certificates. Training records were reviewed. Administrator Certificate for Sarah Araya, 6010373740 expires on 4/10/2025.

Administrator agreed to submit updates of forms by 1/17/2025: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability Insurance and Surety Bond.

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.

Exit interview was conducted with Administrator and a copy of report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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