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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801205
Report Date: 03/22/2024
Date Signed: 04/04/2024 12:00:04 PM


Document Has Been Signed on 04/04/2024 12:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/04/2024 10:44 AM

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

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**Amend to remove civil penalty and fingerprint clearance citation**

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC case management and met with Caregiver (facility designee) Administrator Arthur Alcones was present via telephone.

On 2/14/2024 LPA conducted the required one year annual inspection at facility. During this inspection, deficiencies were cited for failure to comply with Title 22 regulations 87303(a) and 87705(c)(5), both of which had plan of correction due dates of 3/8/2024. As of today, the plan of corrections for these deficiencies have not been submitted or received by CCL. Per LPA observation main bathroom is almost complete, just needs painting. However, electrical wall faceplate still not repaired. A civil penalty is now being assessed for failure to correct these deficiencies 87303(a) and 87705(c)(5), respectively.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with designee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Facility designee and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/04/2024 12:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/04/2024 10:52 AM

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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2024
Section Cited
CCR
87355(d)

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*Amened to remove deficiency**87355(d) Criminal Record Clearance, All individuals subject to criminal record review shall be fingerprinted.

The licensee has not met this requirement as evidenced by:
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Amended to remove civil penalty and deficiency. Amended to add POC
Admin agrees to have S1 cease working at the facility until fingerprint clearance is obtained. Admin to submit LIC9098 self-certifying S1 is not at facility. Immediate Civil Penalty assessed for $500
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*Amended to remove deficiency**Based on LPA observation and Guardian database review, staff (S1) does not have fingerprint clearance, which poses a health, safety or personal rights risk to persons in care. Civil penalty assessed.
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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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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