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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803583
Report Date: 11/08/2024
Date Signed: 11/08/2024 11:47:20 AM

Document Has Been Signed on 11/08/2024 11:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALCHEMIAFACILITY NUMBER:
496803583
ADMINISTRATOR/
DIRECTOR:		LIZ JAHRENFACILITY TYPE:
775
ADDRESS:394 TESCONI COURTTELEPHONE:
(707) 978-3229
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 45CENSUS: 35DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Mary Gannon Graham (Artist Coordinator)TIME VISIT/
INSPECTION COMPLETED:
12:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Mary Gannon Graham, Artist Coordinator. The program is open Monday through Friday from 9:00am to 3:00pm. Required postings were observed. Annual fees are current.

LPA initiated a tour of the facility at 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Participants were participating in various activities in classrooms with their Mentors. Participants bring their own lunches which are stored in lockers. Bathrooms had hand rails for safety and appeared sanitary. Water temperature read at 106.7 F which are within regulation of 105 and 120 degrees F. Toxins were inspected and are stored in a locked closet located in the staff room that was also locked. Fire extinguishers were last serviced August, 2024. Facility has a centralized smoke detector system that is maintained by a vendor and inspected by the local fire department. Most recent service was conducted August 2024. Last disaster drill was conducted on 10/17/24. Facility does not provide transportation, handle medications or cash resources.

LPA initiated at 9:30am file review of five staff and ten participant files. Staff files reviewed do not have required First Aid, CPR Certificates. All staff have at least eight hours of training documented on file. Participant files have needs and services plans updated, but five out of ten participants (P2-P6) medical assessments were not on file.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALCHEMIA
FACILITY NUMBER: 496803583
VISIT DATE: 11/08/2024
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Continues from LIC809...

During today's visit, LPA followed up on two incident reports received at Regional Office. Per incident reports, On 10/3/24 afternoon participant (P1) reported to artist mentors that they have suicidal thoughts due to P1 is mad at God for taking their mother and other family members. P1 stated that they probably would not kill themselves because they would not be able to see their loved ones again. Upon staff been aware of P1's feelings, they had a conversation with P1 about the seriousness of making such a statement and encouraged P1 to reach out to their physician to get referred to a professional to speak with about these thoughts and feelings. Staff also provided P1 with a crisis number to call the suicide hotline. Staff monitored P1 closely and cross reported the incident to pertinent agencies. Another incident was reported to CCL, on 11/7/24 after lunch time, P1 started getting upset about their recent breakup with their partner, staff took a walk to the bench outside and P1 stated they partner make them so upset that sometimes they think about killing themselves, and these thoughts of self harm have been happening since their mom died, but because they promise their mom and dog they won't actually do it. Staff discussed with P1 calming strategies and referral to a therapist for guidance and support. The facility reported to P1's responsible parties including placement agency and CCL. Based on records review, P1's physician report described that P1 has a diagnosis of depression and epilepsy. Also, P1 is able to manage their medication. However, their individual care plan dated 12/18/23 identifies areas of concern including P1 feeling overwhelmed by events and attempting suicide by overdosing on their medications. LPA had a conversation with Artist Coordinator regarding the areas of concern identified in their individual program plan. According to Artist Coordinator, P1 lives with their family and they have reported to their responsible parties, the facility is providing guidance and supporting them as well as closely monitoring them while they are in the day program.
Facility provided updated copies of the following documents: Designation of Responsibility (LIC308), Personnel Report (LIC500) and control of property.

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 Artist Coordinator. A copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 11:47 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/08/2024 at 11:25 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: ALCHEMIA
FACILITY NUMBER: 496803583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Artist Coordinator's observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 10 participant's medical assessments were not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
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Facility agreed to obtain current medical assessments for all participants and facility will submit a self-certification LIC9098 form to CCL by POC due date of 12/02/2024.
Type B
Section Cited
HSC
1569.618(c)(3)

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record's review and interview with Artist Coordinator, the licensee did not have at least one staff member who has CPR training on duty at all times. Facility has 4 out of 4 Artist Mentors that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.
POC Due Date: 12/02/2024
Plan of Correction
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Licensee to ensure that staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that at least staff has been certified for CPR per regulation and that facility will maintain a staff on duty who has CPR training at all times. Self certification to be submitted by POC date of 12/02/2024
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: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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