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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803289
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:03:24 PM

Document Has Been Signed on 03/04/2024 03:03 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:BEACHWOOD HOUSE, INC.FACILITY NUMBER:
496803289
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:1177 BEACHWOOD DRIVETELEPHONE:
(707) 332-9865
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 4CENSUS: 4DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Jhanell Edmalin (House Manager)TIME COMPLETED:
03:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with House Manager, Jhanell Edmalin. Annual fees are current. Required postings were observed.

LPA/staff initiated a tour of the facility at 1:20 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 110.6 and 108.1 which are within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable food was available. Toxins are located in a cabinet in the garage that was not locked during inspection. Medication is centrally stored and locked in a cabinet in the kitchen. Fire extinguishers were last inspected June 16, 2023. Smoke detectors located throughout the facility and the carbon monoxide detector were tested and operational during inspection. Cash resources, medication and medication records were reviewed. Emergency supplies were observed with a first aid kit fully stocked. Most recent disaster drill was conducted September, 2023.

LPA initiated file review at 1:40pm. Four client files and two staff files were reviewed. First Aid certificates for staff are current. Administrator Certificate for Benjamin Cabie, 6026669735, expires on 5/30/25.

Facility to update the following forms and submit to CCL by 3/15/2024: (LIC308) Designation of Administrative Responsibility, (LIC500) Personnel Report, surety bond (LIC610E) Emergency Disaster Plan (if any changes)

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 House Manager and copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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Document Has Been Signed on 03/04/2024 03:03 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/04/2024 at 02:55 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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the administrator did not comply with the section cited above in 1 out of 1 facilty quarterly disaster drills were not conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Facility to ensure that facility will conduct quarterly disaster drills as required by Health & Sfety Code. Administrator to submit to CCL proof of disaster drill conducted wiht the facility by POC date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
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