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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:58:43 PM

Document Has Been Signed on 02/04/2025 03:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AA BEST CARE HOMESFACILITY NUMBER:
496801684
ADMINISTRATOR/
DIRECTOR:
AQUINO, NICANORFACILITY TYPE:
740
ADDRESS:857 HEARN AVE.TELEPHONE:
(707) 546-8413
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 40CENSUS: 24DATE:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:18 PM
MET WITH:Administrative Assistant, Charito SantosTIME VISIT/
INSPECTION COMPLETED:
04:13 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management investigation and was greeted by House Manager/Administrative Assistant, Charito Santos. Administrator Nicanor Aquino is out of the country and not available.

On 2/3/25 CCL received from facility an Incident Report pertaining to resident (R1). On 1/31/25, R1 was taken by ambulance to the hospital after R1 was unable to walk or put pressure on their leg. Facility staff S1 noticed that R1 had a wound on their ankle. R1 was transported from the facility to the hospital by ambulance due to R1 being unable to walk or put pressure on their leg. All required parties notified. On 2/1/25, the facility was notified that R1 had passed away.

LPA conducted interviews, reviewed documents, and received copies of documents.

LPA's review of R1's most recent Appraisal, Needs, and Services Plan (LIC625) indicates that R1 takes care of their own grooming, showers themselves, but needs reminding to change their incontinence brief. LPA's review of R1's most recent physician's report (LIC602) indicates that R1's capacity for self-care is affirmative with the exception of managing their own cash resources; R1 has the ability to bathe, dress, feed, groom, and care for their own toileting needs.

LPA interviewed S1 and asked if they had ever noticed a wound on R1's ankle or if R1 ever had any wounds period. S1 answered that they had never seen any wound on R1 before this morning. S1 explained they saw the wound as they were helping the resident to their feet and with their incontinence brief. S1 explained that R1's medical diagnosis sometimes impairs them and it is during these times that they help R1 with stability. S1 always goes in at the beginning of their shift to change the bed chucks and see if R1 has a soiled brief. R1 does not always soil their briefs, they only wear them in case of accidents. S1 asked R1 to stand and that
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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AA BEST CARE HOMES
FACILITY NUMBER: 496801684
VISIT DATE: 02/04/2025
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is when R1 told S1 that they could not stand without too much pain. S1 noticed the wound on R1's ankle and asked them how the wound got there. R1 answered that they did not know. S1 asked R1 how long has the wound been there because they never saw it before, R1 answered that they did not know.

LPA interviewed HM. HM reported to LPA that R1's responsible party (RP) indicated that there was an issue with R1's lungs as they had a long history of smoking and that this was probably the reason for R1's passing but they were not sure. HM reported to LPA that they have asked R1's RP for R1's Death Certificate to provide to CCL once received.

No deficiencies cited during this visit.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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