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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803583
Report Date: 08/17/2023
Date Signed: 08/17/2023 12:40:06 PM

Document Has Been Signed on 08/17/2023 12:40 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:ALCHEMIAFACILITY NUMBER:
496803583
ADMINISTRATOR:LIZ JAHRENFACILITY TYPE:
775
ADDRESS:394 TESCONI COURTTELEPHONE:
(707) 978-3229
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 45CENSUS: 40DATE:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Mary Gannon (Staff/Mentor Supervisor)TIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPAs) Cuadra and Coppo conducted an unannounced case management inspection. LPAs arrived to the facility and met with Mary Gannon Staff Supervisor. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL) on 7/31/23

Per incident report, on 7/31/23 at approximate 10:30am participant (P1) told Artist Coordinator staff that their blood sugar was at 100. Staff suggested to P1 to eat some fruit from their lunch, re-check their blood sugar levels and report back later. Prior to lunch time, staff checked on P1 and was told that their levels were better. After eating lunch P1 went to the bathroom, rang the emergency bell, staff unlocked bathroom door and found P1 laying on the floor unresponsive, 911 was contacted, they stabilized P1 and transported them to the hospital for further evaluation. Day program notified responsible parties and were told that a reading of 100 was normal for P1.

During today's visit, LPAs reviewed records and conducted interviews with staff regarding the incident and were told that they don't conduct a meter check to check participant's blood sugar levels because they are not medical licensed. However, P1 checks their blood sugar levels frequently. P1's home mentor provided a six pack of juice boxes and P1 will carry glucose tablets to have them at all times to prevent incidents like this one from happening again. The facility is in the process to update P1's Physician report and individualized service plan. The Department will review documents obtained to determine if further action is needed.

No deficiencies cited during today's inspection. Exit interview conducted with Staff Supervisor and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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