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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801432
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:38:05 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/10/2024 02:38 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/
DIRECTOR:		GOMES, RAQUELFACILITY TYPE:
735
ADDRESS:803 NORTH DUTTON AVE.TELEPHONE:
(707) 526-4081
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 3DATE:
09/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Raquel Gomes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived at facility unannounced to complete this facilities Annual Required Inspection that began on 9/6/2024. LPA was greeted by Administrator, Raquel Gomes. Clients were attending day program at the time of the visit.

At 1:15 PM LPA and Administrator toured the facility. Water temperature in client bathrooms measured at 129.9 degrees F in 2 out of 2 bathrooms, falling out of allowable range of 105 to 120 degrees F.(see LIC809-D) Extra hygiene products and linens were available.

AT 1:25 PM 5 staff files were reviewed and LPA learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for all staff.

At 1:50 PM medications and medication records were reviewed. Cash Resources were reviewed, which were not co-mingled.



Administrator agreed to provide the following documents by 9/25/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E) updated Surety Bond & control of property (updated lease agreement).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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Document Has Been Signed on 09/10/2024 02:38 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/10/2024 at 02:14 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: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
80088(e)(1)

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80088(e)(1)Furniture, Fixtures..- (e)(1) Hot water temperature controls shall be maintained to... attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F.
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Facility decreased the water temperature during visit. Facility agrees to keep a daily log of temperature for 2 weeks. Facility to send in written statement they understand regulation 80088(e)(1). by POC due date 9/25/2024 with log showing water temp is within regulation to clear citation.
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 **This requirement was not met as evidenced by: Based on observation during today's visit water tested in 2 of 2 bathrooms read at 129.9 and129.9 Degrees F . This is a potential health and safety risk to clients in care.
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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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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