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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803398
Report Date: 12/10/2021
Date Signed: 12/10/2021 12:49:19 PM

Document Has Been Signed on 12/10/2021 12:49 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PROGRESS FOUNDATION-PARKER HILL PLACEFACILITY NUMBER:
496803398
ADMINISTRATOR:LONG, MATTHEWFACILITY TYPE:
772
ADDRESS:3371 PARKER HILL ROADTELEPHONE:
(707) 535-0289
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 12CENSUS: 10DATE:
12/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Janeen Vierra Taylor, Program DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analysts Victoria Willis and Caitlynn Felias arrived unannounced to conduct a Case Management inspection and met with Program Director, Janeen Vierra Taylor.

Facility submitted an incident report for client, C1 for a medication error. According to interview, C1 was accidentally given medication at dinner instead of bedtime, as prescribed. Another dose of the medication was then given at bedtime resulting in C1 receiving two doses in error. Per interview, the second error occurred because of confusion during documentation of a medication change. C1 had no adverse affects due to to error. Additional staff training was conducted.

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 Willis
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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 12/10/2021 12:49 PM - It Cannot Be Edited


Created By: Victoria Willis On 12/10/2021 at 12:33 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PROGRESS FOUNDATION-PARKER HILL PLACE
FACILITY NUMBER: 496803398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2021
Section Cited
CCR
81075(b)

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81075 Health-Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement has not been met as evidenced by file review and interview showing that client, C1 was given medication at an incorrect time resulting in
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Facility has conducted additional training. Deficiency is cleared.
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 C1 receiving two doses of the same medication within a 24 hour period. This is an immediate risk to the health and safety of clients 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 Willis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021


LIC809 (FAS) - (06/04)
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