496801929-12-15-2023-21-AS-MCUA-CYJUAV-20231215142521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801929
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:25:31 PM

Document Has Been Signed on 12/15/2023 02:25 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:	FRIENDS HOUSE		FACILITY NUMBER:	496801929
ADMINISTRATOR:	ROBERT RUBIO		FACILITY TYPE:	741
ADDRESS:	684 BENICIA DRIVE		TELEPHONE:	(707) 538-0152
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	145	CENSUS: 9	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Robert Rubio (Executive Director)		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra conducted an unannounced Required - 1 Year annual inspection and met with Executive Director, Robert Rubio. There are currently 9 residents living in the Assisted Living (AL) portion of the facility and 83 residents living in the Independent Living (IL) portion of the community. There are residents with a diagnosis of dementia and no residents were receiving hospice care at the time of the visit. Required postings were observed. Facility contact information was reviewed. Fees are current at the time of visit. Beginning at 9:00 AM, LPA/Administrator toured assisted living portion of the community including the resident rooms/apartments, activity rooms, grounds and kitchen (located in the assisted living). All interior parts of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured between 112.8 and 113.4 F in faucets used by residents which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Bathrooms contained necessary grab bars and non-slip floor/mats. Toxins were observed to be inaccessible in the Assisted Living portion of the community. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. Medications are centrally stored in a locked office in the assisted living building. Fire extinguishers were current and charged as of October 2023. Fire alarm system was tested and inspected and documentation of last semi-annual inspection conducted on 11/29/2023 was provided during the visit. A disaster drill was conducted on September 2023. Carbon monoxide detectors were observed to be present and in working order. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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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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: FRIENDS HOUSE	FACILITY NUMBER: 496801929
	VISIT DATE: 12/15/2023

NARRATIVE

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Continues from LIC809...

LPA initiated file review at 10:00am nine resident and five staff records. Six out of nine residents (R1, R2, R3, R4, R5 & R6) care plans has not been updated within the last 12 months. One out of nine residents (R3) has not been updated within the last 12 months. Five staff records were reviewed. Staff have CPR/1st aid certificate. Two out of five staff (S1 & S2) does not have 20 hours of required annual training on file. A spot check of Medication and medication records was also conducted. Administrator Robert Rubio's Certificate 6054931740 expires 1/21/2024.

Administrator agrees to submit the following documents updates to CCL by 12/22/2023:

-LIC308 - Designation of Administrator Responsibility
-LIC500 - Personnel Report
-Updated Liability Insurance Certificate.
-Control of property.
-LIC610E - Emergency Disaster Plan & Updated Evacuation Plan

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

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/15/2023 02:25 PM - 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: FRIENDS HOUSE	FACILITY NUMBER: 496801929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 2 out of 5 staff did not have annual required training hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have all staff take additional training hours needed and will submit a LIC9098 self-certification form to CCL by POC due date ensuring staff have required training hours on file.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 1 out of 9 residents (R3) did not have a current medical assessment within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator agrees to obtain a current medical assessment for resident (R3) and will submit a LIC9098 self-certification form to CCL by POC due date.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/15/2023 02:25 PM - 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: FRIENDS HOUSE	FACILITY NUMBER: 496801929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 6 out of 9 resident's care plans were not updated within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete resident's care plans with residents/responsible parties and will submit a self-certification LIC9098 by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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