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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801432
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:33:18 PM

Document Has Been Signed on 07/07/2022 02:33 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 DUTTON AVENUE MANORFACILITY NUMBER:
496801432
ADMINISTRATOR:GOMES, RAQUELFACILITY TYPE:
735
ADDRESS:803 NORTH DUTTON AVE.TELEPHONE:
(707) 526-4081
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Raquel Gomes (Administrator)TIME COMPLETED:
02:48 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by staff Vernada Townsend. Administrator, Raquel Gomes was not able to come to the facility, but was available by phone and gave authorization to staff to sign the report. During today's visit North Bay Representative Angie Garcia was also present in the facility.

LPA arrived at the facility and have their temperature checked and logged into a sign-in sheet. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Smoke detectors and last disaster drill were conducted and checked on 12/27/21 and fire extinguisher were last serviced on May 2022. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least twice a day. Facility is allowing indoor visitations and has antigen tests available to use for visitors. Facility is able to accommodate a single room for each client that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and has been N-95 fit tested. Staff and residents are being monitored daily and results are documented in a binder. Facility maintains a 30 day supply of medication. Facility has 100% vaccination rate and boosters for all staff and clients. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Three out of four clients do attend to day program two to three days per week in average. Facility has submitted their Covid Mitigation Plan and approved on 8/2/21. Facility has submitted Infection Control Plan for CCL's review. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, hand sanitizer, etc. PPE supplies are located in an accessible place for staff.


Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SARAH'S DUTTON AVENUE MANOR
FACILITY NUMBER: 496801432
VISIT DATE: 07/07/2022
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At approximate 1:45pm LPA/staff observed expired food; There was 7 full bags of wheat bread, 3 cups of 16oz of peanut butter, 4 boxes of cultured vegan butter, 6 packets of 9oz of sliced oven roasted turkey and ham, 2 gallons of reduced milk in the facility refrigerator and pantry.

Administrator will submit updated copies of the following by 7/14/22: affidavit regarding client/resident cash resources (LIC400) and surety bond.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2022 02:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 07/07/2022 at 02:18 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 DUTTON AVENUE MANOR
FACILITY NUMBER: 496801432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted with staff, the facility did not ensure that expired food located in the pantry and in the refrigerator was discarded after their expiration date which is an immediate health and safety risk to residents in care.
POC Due Date: 07/08/2022
Plan of Correction
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Administrator to submit a written plan of maintenance regarding ensuring all food is of good quality at all times-and refrigerator is checked regularly for this. Administrator to check refrigerator and pantry and will discard any expired food and submit written confirmation of doing this by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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