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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:16:03 AM


Document Has Been Signed on 11/08/2022 10:16 AM - 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: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: 30DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charito Santos (Administrator)TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management and met with facility Administrator, Charito Santos.

LPA is following up on a self-incident report filed by the facility Administrator to CCL on 11/1/22. Per incident report, On 10/26/22 around 12:50pm resident (R1) went to the bathroom sat down in the toilet bowl and couldn't get up informing roommate that had a back pain. Staff called 911 immediately and transported R1 to Sutter Hospital. R1 was discharged same day with a diagnosed of closed wedge compression fracture of T12 vertebra after a fall.

During today's visit, LPA reviewed R1's records including their care plan, Physician's Report (LIC602) and discharge documents dated 10/26/22 indicating that R1 sustained a fracture and follow up appointment on 11/7/22 with R1's Physician were it was determined that R1 does not need surgery and has another follow up appointment on 12/16/22. LPA also made observations to residents in care and conducted interviews with facility staff and residents that concluded R1 had an un-witnessed fall while using the restroom. Based on Physician's report (LIC602) dated 9/22/15 and R1's care plan dated 7/18/18 R1 is able to perform ADL's independently. LPA advised Administrator to update R1's records. Administrator agreed to update resident's records.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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