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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 12/08/2023
Date Signed: 12/08/2023 09:55:12 AM


Document Has Been Signed on 12/08/2023 09:55 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: 28DATE:
12/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Charito Santos (Administrative Assistant)TIME COMPLETED:
10:09 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a health check visit and met with facility Administrative Assistant, Charito Santos. This case management inspection is to conduct a health and safety check and ensure that facility is clean and good repair.

Upon entrance to the facility, LPA/staff observed a sign stating that living room will be open until 5am. Per Administrator, on 12/6/23 there was an incident where one resident have urinated and defecated in the living room, and they have to close the living room for cleaning. During today's visit, LPA conducted confidential interviews with staff and residents in care who indicated that the living room was closed two days ago for a couple hours only. Although, staff did not take the sign off the door, there are no indications that living room was closed for more than two hours for cleaning, residents were observed in the living room engaged in activities as well as watching the television.

LPA/staff toured the facility and observed one of resident's bedroom door was missing and piece of cloth was clipped to the door frame to ensure resident's privacy. Per Charito, the resident who sleeps in the bedroom experiences aggressive behaviors when closing forcefully the door, the hinges were loose, so staff removed the door to fix it since 12/2/23 afternoon and it has not been fixed yet.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. ***civil penalties are issued for repeated violation in the amount of $250. Exit interview was conducted with Administrative Assistant and copy of the report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/08/2023 09:55 AM - It Cannot Be Edited

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: AA BEST CARE HOMES
FACILITY NUMBER: 496801684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2023
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Licensee agreed to repair the door to ensure resident's privacy. Licensee will submit self-certification LIC9098 form along with picture to indicate that repairs are within CCL regulations by POC due date.
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Based on observation, the licensee did not comply with the section cited above because LPA/staff observed one resident's bedroom door was missing, which poses an immediate health, safety or personal rights risk to persons in care.
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*civil penalties are issued for repeated violation in the amount of $250.

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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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