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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:23:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:AA BEST CARE HOMESFACILITY NUMBER:
496801684
ADMINISTRATOR:AQUINO, NICANORFACILITY TYPE:
740
ADDRESS:857 HEARN AVE.TELEPHONE:
(707) 546-8413
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:40CENSUS: 32DATE:
12/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Charito Santos (Administrator)TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Administrator, Charito Santos. LPA conducted risk assessment with staff. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

LPA is following up on four incident reports submitted to CCL: On 11/20/21 resident (R1) was walking towards the dining room outbalanced and had a fall, facility staff called 911 and paramedics transported R1 to Santa Rosa Memorial Hospital. R1 was diagnosed with dislocation of finger, no new medications were prescribed, responsible parties were notified. Per Administrator, R1 is doing better

-On 11/18/21 resident (R2) complained of having a hard time breathing, staff called 911, paramedics transported R2 to Santa Rosa Memorial Hospital then was transferred to summerfield rehabilitation center and does not have a discharge date yet.

-On 11/25/21 around 6:45am resident (R3) had their roommate called facility staff alleging that they had a fall, had foot pain, staff found R3 in a sitting position, called paramedics who transport R3 to Sutter Hospital. R3 was diagnosed with anxiety, no new medications were prescribed and responsible parties were notified. During today's visit LPA reviewed discharge documents and R3 was discharged with a follow up appointment on 12/17/21 and lab tests were performed. On 11/29/21 around midnight R3 had an un-witnessed fall while in the bathroom, paramedics were contacted and they transported R3 to the emergency room, resident came back the same day with no new medication. During today's Administrator informed LPA that R3 had another incident on 12/2/21 around 7:40am, R3's roommate came to the office to notify staff that R3 stated that they had an un-witnessed fall, staff found R3 sitting in their wheelchair with no apparent injuries, paramedics were called and R3 was transported to emergency room. Currently, resident is still in the hospital. Administrator agreed to submit discharge documents as soon as the resident comes back.
No deficiencies were issued during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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