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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803630
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:45:23 PM

Document Has Been Signed on 01/20/2023 02:45 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: 5DATE:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH: Ely Valenzuela -RN TIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 1/20/23 at approximately 10:00am, and met with RN Ely Valenzuela. LPA observed three additional staff/caregivers on duty during the inspection. There were four clients in care, and one resident at a scheduled medical appointment.

This inspection is to follow-up on the Semi Annual Report recently conducted by CDDS.
LPA reviewed the report findings with Ely, RN Lead Staff, and reviewed all items, obtaining additional information from Administration staff. LPA documented information as needed, and reviewed information with Administrator Jennica Narciso and RN Ely Valenzuela.

LPA discussed with Administrator the facility reporting requirements, and reviewed Health and Safety Code. The LPA also discussed regulations regarding the DDS report LPA reviewed with the Administrator. Administrator stated their understanding of above items discussed.

Per LPA's review, a serious client incident was not reported as required, and this deficiency will be cited, 1538.55(a) Events requiring reports by licensee; notice of findings, see LIC809D.

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

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: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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Document Has Been Signed on 01/20/2023 02:45 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/20/2023 at 02:00 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2023
Section Cited
HSC
1538.55(a)

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1538.55(a)Events requiring reports by licensee; notice of findings- The licensee of an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) , licensed pursuant to Article 9 (commencing with Section 1567.50), shall report to the
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Administrator to ensure that all required incidents are reported per H&S Code 1538.55(a); Hold an in-service training with all care giving staff and administration staff regarding the above H&S Code, and ensure the facility operates in compliance at all times with required reporting.
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department’s CCLD, within the department’s next working day the regional center, and the State DDS, within 24 hours upon the occurrence of any of the following events listed. This requirement was not met as evidenced by review of records/reports/interviews. Serious Incident of C1,10/12/22 was not reported by phone and written report to CCL. This is a personal rights and health and safety risk to clients in care.
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Submit proof of training by 1/30/23, include Trainer, Qualifications, Topics, Attendees, Date/Time spent. Plan of correction to be submitted by 1/21/23.

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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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023


LIC809 (FAS) - (06/04)
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