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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801932
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:09:19 AM

Document Has Been Signed on 07/27/2023 11:09 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DUNGARVIN CALIFORNIA LLCFACILITY NUMBER:
496801932
ADMINISTRATOR:FAIRCHILD, CARRIEFACILITY TYPE:
775
ADDRESS:433-439 BEAVER STTELEPHONE:
(707) 543-5895
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 75CENSUS: 31DATE:
07/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Day Services Manager, Shannon DavisTIME COMPLETED:
11:20 AM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Day Services Manager, Shannon Davis.

LPA is following up regarding a self-reported incident where client, C1 was riding in a vehicle but was not properly secured causing their wheelchair to tip backward. C1 was not hurt.

Involved staff has been retrained to ensure safety of clients moving forward. Facility has also updated their protocol to have additional staff double check that clients are properly secured in transportation vehicles.

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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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Document Has Been Signed on 07/27/2023 11:09 AM - It Cannot Be Edited


Created By: Victoria Bertozzi On 07/27/2023 at 10:49 AM
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: DUNGARVIN CALIFORNIA LLC
FACILITY NUMBER: 496801932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met based on interview and document review showing that client was not properly secured in facility transportation vehicle causing
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Facility has provided additional training to noted staff and updated their protocol to have additional staff double check that clients are secured. Deficiency is cleared.
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their wheelchair to tip backward. This is an immediate health and safety risk to client in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


LIC809 (FAS) - (06/04)
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