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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801313
Report Date: 04/29/2024
Date Signed: 04/29/2024 05:49:33 PM

Document Has Been Signed on 04/29/2024 05:49 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 YOUNG ADULT HOMEFACILITY NUMBER:
496801313
ADMINISTRATOR/
DIRECTOR:		GREGORI, LINDSEYFACILITY TYPE:
735
ADDRESS:1520 GRIFFIN WAYTELEPHONE:
(707) 585-6223
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 4DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Lindsey Gregori-AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso arrived to conduct a Required - 1 Year visit, and met with Administrator Lindsey Gregori. There are four(4) clients in care at this facility, all are ambulatory. Administrator Lindsey has an Administrator Certificate, #6017082735, expires 5/27/24.

The clients all attend day program. LPA reviewed four (4) client files. All files were complete.

LPA reviewed three staff files. All staff have criminal record clearance as required. Staff have training as required by regulation. All staff have First Aid certification, and CPR certification.

LPA toured the facility with the Administrator Lindsey. Fire extinguishers, two(2), are tagged and inspected as required. Carbon monoxide detector was working properly as required. All exits doors, and hallways/walkways were unobstructed as required.

Facility has a sufficient supply of food. Facility has a sufficient supply of cleaners/disinfectants. Facility has a sufficient supply of hygiene products, linens, and paper products. The facility has a sufficient supply of personal protective equipment(PPE). The client rooms, hallways, bathrooms, and common areas all had sufficient lighting.

Per LPA's record reviews, facility lacked a required disaster & mass casualty plan. This will be cited,80023(a) Disaster & Mass Casualty Plan- (a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action, see LIC809D.

Continued on LIC809C...

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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 4
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 YOUNG ADULT HOME
FACILITY NUMBER: 496801313
VISIT DATE: 04/29/2024
NARRATIVE
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LPA observed that the clients’ hallway bathroom’ and client’s private bedroom bathroom, both had mold all around the tub/shower where the caulking was all worn away and/or worn down; The tub/showers were dirty, moldy, and needed to be sanitized, in good repair, and cleaned. This deficiency will be cited, 80088 ( e)(3) Furniture, Fixtures, Equipment, and Supplies - All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items, see LIC809D.

Per LPA's review of records, facility lacks a required infection control plan. This will be cited, Infection Control Requirements 85095.5(c)- An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022, see LIC809D.

The following citations are being issued under Title 22, Division 6 of the California Code of Regulation. Failure to correct deficiencies by POC due dates, may result in civil penalty citations.



Appeal Rights given.
Exit interview conducted with the Administrator Lindsey Gregori.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/29/2024 05:49 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/29/2024 at 05:27 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: SARAH'S YOUNG ADULT HOME
FACILITY NUMBER: 496801313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's review of records, facility lacks a required infection control plan, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Licensee to ensure that the facility completes a written infection control plan as required. Submit a copy to the licensing office by 5/10/24. POC due 5/10/24.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed that the clients’ hallway bathroom’ and client’s private bedroom bathroom, both had mold all around the tub/shower where the caulking was all worn away and/or worn down; The tub/showers were dirty, moldy, and needed to be sanitized, in good repair, and cleaned, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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Licensee/Administrator to ensure that both facility bathrooms get cleaned, disinfected, and have caulking in tub/showers as needed. Submit plan of continued maintainance to ensure compliance with this regulation. Submit pictures of the bathroom tubs/showers once corrected. POC due by 5/6/2024.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/29/2024 05:49 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/29/2024 at 05:27 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: SARAH'S YOUNG ADULT HOME
FACILITY NUMBER: 496801313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Per LPA's record reviews, facility lacked a required disaster & mass casualty plan. the licensee did not comply with the section cited above,] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Licensee to ensure that the facility completes a written disaster & mass casualty plan as required. Submit a copy to the licensing office by 5/10/24. POC due 5/10/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
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