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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802043
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:05:32 PM

Document Has Been Signed on 05/13/2024 03:05 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:PROGRESS SONOMAFACILITY NUMBER:
496802043
ADMINISTRATOR/
DIRECTOR:		ELIZABETH PICKERINGFACILITY TYPE:
772
ADDRESS:3400 MONTGOMERY DRIVETELEPHONE:
(707) 526-6902
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 10CENSUS: 8DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:48 AM
MET WITH:Elizabeth Pickering, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Counselor. Program Director (PD) Racquel Raval arrived shortly after. Elizabeth Pickering, Administrator (Admin) arrived at approximately 10:00am. Facility contact information was reviewed.

At approximately 9:45am LPA and PD toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 126 degrees F which is not within the allowable range of 105 to 120 degrees F. PD immediately turned down water heater.

Fire extinguishers were last inspected 1/4/2024. Smoke/Carbon Monoxide detector was tested by LPA and found to be operational. Facility’s last quarterly disaster drill was conducted on 4/18/2024.

At approximately 12:00pm LPA conducted review of five [5] staff records. All required documentation present. At approximately 1:00pm LPA conducted a review of six [6] of eight [8] resident records. All required documentation present.

At approximately 2:15pm LPA and PD conducted a spot check of medication and medication records. Medication is centrally stored in locked lockers in staff office room.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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: PROGRESS SONOMA
FACILITY NUMBER: 496802043
VISIT DATE: 05/13/2024
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Continued from 809...

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

On 4/22/2024 CCL received an Incident Report for resident (R1) indicating resident "accessed" medications that were prescribed to another resident. Per Admin, facility uses the term accessed to indicate help with self-administration of medication. Staff relief counselor (S1) gave the R1 medication that was prescribed to a different resident. R1 was given 200mg of Seroquel, 100mg of Depakote, and 1 mg of Avtivan in error. Upon giving the medication to R1, S1 immediately realized their mistake and called to consult with a nurse on duty at Crisis Stabilization Unit. Nurse directed S1 to monitor R1 for adverse reactions. R1 was then taken to the Emergency Room as a precaution. R1 was monitored for 48 hours after returning from the ER and no adverse reactions were observed or reported. Per Admn, the facility immediately suspended S1 from monitoring medications until facility retrained S1. On 4/29/2024 facility PD met with S1 and went over Mandatory Medication Protocol. PD met with S1 again on 5/2/2024, 5/8/2024 and 5/9/2024 to do mock medication monitoring and review medication pages and codes, with an emphasis on knowing the difference between the pages and the codes. Upon successful completion of training S1 had their medication monitoring privilege reinstated. Admin provided LPA with training record (deficiency cited, see 809D).

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

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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2024 03:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/13/2024 at 01:56 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: PROGRESS SONOMA
FACILITY NUMBER: 496802043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81075(b)
81075 Health-Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review of Incident report, the licensee did not comply with the section cited above in that R1 was given medication that was prescribed to a different resident, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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On 4/20/2024 facility immediately suspended S1 from monitoring medications until facility retrained S1. On 4/29/2024 facility PD met with S1 and went over Mandatory Medication Protocol. PD met with S1 again on 5/2, 5/8 and 5/9/2024 to do mock medication monitoring and review medication pages and codes, with an emphasis on knowing the difference between the pages and the codes. Admin provided LPA with training record. Deficincy cleared
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
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