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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803630
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:46:36 PM

Document Has Been Signed on 12/21/2023 02:46 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:PETERSON LANE HOMEFACILITY NUMBER:
496803630
ADMINISTRATOR:NARCISO, JENNICA AFACILITY TYPE:
734
ADDRESS:1618 PETERSON LANETELEPHONE:
(707) 978-2573
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 5CENSUS: 4DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennica-Abbie-Narciso-Administrator/RNTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required-1 Yeart inspection, on 12/21/23 at approximately 9:50am, and met with Abbie Narciso, Administrator/RN. LPA observed two caregivers/DSPs on duty during the inspection. All four (4) clients were at day program.

Emergency drills are held monthly, a fire drill was held on 12/6/23, and a tornado drill on 12/8/23. Facility is fire cleared for five (5) clients that are non-ambulatory, of which five (5) may be bedridden. Facility has a signal system on all exit doors. The facility has a generator as their 2nd required power source. The generators run a check once every week to ensure they are working properly. The fire extinguishers were serviced and tagged as required. All exits were unobstructed. Smoke alarms are hard wired, home is also fire sprinkled, and have two carbon monoxide detectors. The facility was clean and orderly. The facility was observed to be at a comfortable temperature. All bathrooms have grab bars, and roll in showers. The facility had a sufficient supply of food, hygiene products, cleaners, incontinent supplies, personal protective equipment, and paper supplies. Facility had sufficient furnishings. All common areas, hallways, and resident rooms have sufficient lighting. Hot water was checked at 114.8 degrees Fahrenheit.

LPA requested the following updated documents by 1/21/24.
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Fire Alarm System Test
Updated facility sketch
Emergency Disaster Plan- if any changes, submit a copy- if no changes, please sign and date and submit copy (last page)
LIC 400- Affidavit regarding Client Cash Resources
Surety Bond
Most up-to-date Liability insurance
Register of residents

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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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: PETERSON LANE HOME
FACILITY NUMBER: 496803630
VISIT DATE: 12/21/2023
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LPA reviewed a client incident report, 10/16/23, on C3;This was a medication error, C3 didn't receive a medication, 1 tab, as ordered by the Physician. This deficiency will be cited, 80075(b)(5)(B)) Health Related Services- Once ordered by the physician the medication is given according to the physician's directions, see LIC809D.

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code.

Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Abbie Narciso. Appeal rights provided.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2023 02:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/21/2023 at 02:24 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: PETERSON LANE HOME
FACILITY NUMBER: 496803630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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CLEARED- Licensee held an in-service, 10/20/23, on Medication Management with all nurses that assist the clients with medications. Administrator provided proof of training to the LPA.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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