496801929-12-5-2024-21-AS-CCOO-DBP3HZ-20241205171647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801929
Report Date: 12/05/2024
Date Signed: 12/05/2024 05:16:58 PM

Document Has Been Signed on 12/05/2024 05:16 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	FRIENDS HOUSE		FACILITY NUMBER:	496801929
ADMINISTRATOR/ DIRECTOR:	ROBERT RUBIO		FACILITY TYPE:	741
ADDRESS:	684 BENICIA DRIVE		TELEPHONE:	(707) 538-0152
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY: 145	TOTAL ENROLLED CHILDREN: 0	CENSUS: 10	DATE:	12/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:07 PM
MET WITH:	Robert Rubio, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:30 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) Coppo conducted an unannounced annual inspection and met with Administrator Robert Rubio. There are currently 10 residents living in the Assisted Living (AL) portion of the facility and 69 residents living in the Independent Living (IL) portion of the community. Two [2] residents were receiving hospice care at the time of the visit. Required postings were observed. At approximately 1:30pm LPA and Admin 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 119.7 and 109.5 degrees F 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-skid strips. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. Fire extinguishers were current and charged as of 4/4/2024. Fire alarm system was tested and inspected by Santa Rosa Fire Equipment Inc on 4/22/24. Latest disaster drill was conducted on 9/3/24. At approximately 2:00pm LPA conducted a review of 10 resident records. Residents R1 and R2 did not have a TB clearance on file (deficiency, cited, see 809D) Continued on 809C...

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

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: FRIENDS HOUSE	FACILITY NUMBER: 496801929
	VISIT DATE: 12/05/2024

NARRATIVE

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Continued from 809...

At approximately 3:30pm LPA conducted review of 5 staff records. Staff members S1 and S2 did not have 20 hours of annual training completed. S1 had 7 hours and S2 had 10.5 hours (deficiency cited, see 809D)

At approximately 4:15pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies

Robert Rubio Administrator Certificate 7021430740 expires 1/21/26.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/05/2024 05:16 PM - It Cannot Be Edited

Created By: Christi Coppo On 12/05/2024 at 05:01 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FRIENDS HOUSE	FACILITY NUMBER: 496801929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1 and S2 did not have 20 hours of annual training completed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/26/2024
	Plan of Correction
1 2 3 4	Facility to submit copy of trainings completed for S1 and S2 by plan of correction due date

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 and R2 did not have TB clearance on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/26/2024
	Plan of Correction
1 2 3 4	Facility to submit copies of TB clearance for R1 and R2 by plan of correction 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:

Victoria Bertozzi

TELEPHONE: (707) 588-5059

LICENSING EVALUATOR NAME:

Christi Coppo

TELEPHONE: (707) 588-5054

LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC809 (FAS) - (06/04)

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