496801205-4-26-2024-21-AS-VBEI-D55TT3-20240510150005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801205
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:00:28 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20240417171429

FACILITY NAME:	HOEN'S CARE HOME		FACILITY NUMBER:	496801205
ADMINISTRATOR:	ALCONES, LILY O.		FACILITY TYPE:	740
ADDRESS:	1618 MARIPOSA DRIVE		TELEPHONE:	(707) 573-8922
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 6	DATE:	04/26/2024
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Administrator, Lily Alcones		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not ensure that the facility was free of pests.

INVESTIGATION FINDINGS:

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At approximately 2:00PM, Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager (LPM) Victoria Bertozzi arrived at this facility unannounced, to open an investigation into the above allegation.

Complaint alleges facility not free of pests. Based on LPA and LPM observation rodent droppings present in food pantry and in kitchen drawer to the right hand side of the range/oven. Also, waterline from dishwasher to under the sink is leaking and plastic bag appeared to be chewed on. Per Title 22 regulaiton 87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

Based on LPA's observations, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240417171429

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 05/06/2024 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met by licensee as evidenced by:	1 2 3 4 5 6 7	Facility to submit LIC9098, service order from pest control company, and pictures of cleaned up drawer and pantry where dropping where observed by plan of correction due date.
	8 9 10 11 12 13 14	Based on LPA and LPM observed rodent droppings present in food pantry and in kitchen drawer to the right hand side of the range/oven, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

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