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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801117
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:03:04 PM

Document Has Been Signed on 05/29/2024 03:03 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BIRDIE HOUSEFACILITY NUMBER:
496801117
ADMINISTRATOR/
DIRECTOR:		CHRISTINE WOLTERINGFACILITY TYPE:
740
ADDRESS:1402 BIRDIE DRIVETELEPHONE:
(707) 837-9010
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 4DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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At approximately 12:55PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator, Guadalupe Rivera. Licensee, Christine Woltering, was unavailable during visit. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 non-ambulatory residents of which 1 resident can be bedridden. Facility has an approved hospice waiver for 1 individual. Upon arrival, LPA was informed that there were 4 Residents in care and 2 staff members on-site.

At approximately 1:00PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:05PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility is a two story building. The first floor is for residents and the second floor is for live-in staff members. Facility has 8 bedrooms, 2 1/2 bathrooms and common spaces. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2024. Per interview with Administrator, facility's last emergency/disaster drill was conducted April 2024, but documentation was not found during visit (see technical violation, LIC9102, Health and Safety Code, 1569.695(c)). Smoke and carbon monoxide detectors were tested and operational.

At approximately 1:20PM, LPA reviewed staff files, resident files, and resident medications. Files were found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. LPA observed that one staff member was missing 2023 annual training per Health and Safety Code (this deficiency has been cited, see LIC809D, Health and Safety Code 1569.625(b)(2)). Medication was centrally stored and secure.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BIRDIE HOUSE
FACILITY NUMBER: 496801117
VISIT DATE: 05/29/2024
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Continued from LIC809

Administrator's Certificate for Christine Woltering (6033992740) was current with an expiration date of 02/25/2025.

LPA is requesting the following documents to update facility file:


  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 06/29/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 03:03 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 05/29/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BIRDIE HOUSE
FACILITY NUMBER: 496801117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record Review, Licensee did not comply with the section cited above. LPA observed that 1 of 3 staff files did not have the annual trainings completed as required by the Health and Safety Code. This poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee to submit a written plan outlining how they will ensure all staff on site will obtain their annual 20 hour training as required by Health and Safety Code by POC due date of 05/30/2024. Licensee to provide an update on training status to CCL by 06/10/2024 and submit proof of training hours when completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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