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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:16:28 PM


Document Has Been Signed on 09/14/2023 03:16 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: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: 31DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nick Aquino (Administrator)TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced for the purpose of conducting a case management to follow up on self-incident report and met with facility Administrator, Nick Aquino.

LPA is following up on self-incident report filed by the facility Administrator to CCL on 9/8/23. Per incident report, On 9/5/23 around 9:45 am resident (R1) went to the clinic and complained about breathing problem. Clinic staff called 911 immediately and transport them to the Hospital. R1 was admitted to the hospital for further evaluation and discharged on 9/7/23 with a diagnosed of COPD exacerbation and SOB (shortness of breath). During today's visit, LPA reviewed R1's records including their care plan, Physician's Report (LIC602) and discharge documents dated 9/7/23 with no follow up appointment needed with their Physician. LPAs reviewed documents and determined that the Administrator has taken appropriate measures to address the incident.

Exit interview conducted with Administrator and a copy of this report was given.

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: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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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