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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:28:35 PM

Document Has Been Signed on 03/29/2022 12:28 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:HOPE HOUSEFACILITY NUMBER:
496803657
ADMINISTRATOR:MOORE, SHANICEFACILITY TYPE:
735
ADDRESS:1550 N DUTTONTELEPHONE:
(707) 293-4577
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 12CENSUS: 12DATE:
03/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ed Lara (House Manager)TIME COMPLETED:
12:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with House Manager Ed Lara. LPA conducted risk assessment with House Manager at facility entrance. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

During today's visit LPA is following up on an incident report received at CCL on 3/14/22 involving Client (C1). On 3/13/22 at around 3:05pm House Manager noticed on the bubble pack that the Mirtazapine 45mg tablet was still there for the day before 3/12/22 that was supposed to be provided to C1. House Manager inquired with staff who stated that all clients were provided with their medications as prescribed by their Physicians. However, there was no reason why C1 missed a dosage of their prescribed medication. After the incident, house manager notified the Administrator and responsible party. Per house manager, C1's Physician was not contacted because 24 hours after the missed dosage has already passed and no reactions were observed by staff. During today’s visit LPA was informed that the facility will review medication again and will schedule medication training to remind staff to follow physician’s directions and assist clients with their medications as prescribed. House manager agreed to submit records of training that will be conducted with all staff.

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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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 03/29/2022 12:28 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/29/2022 at 11:23 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: HOPE HOUSE
FACILITY NUMBER: 496803657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
80075(b)

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80075(b) Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription & nonprescription medications. This requirement had not been met as evidence by:
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Administrator/House Manager will ensure clients are assisted with their medications when needed. Administrator/House Manager are to schedule and provide a 'facility procedure specific' medication training with staff that handles medications by POC due date 3/3/22.

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Based on records review of facility self-incident report dated 3/14/22 and interviews conducted on 3/29/22 with house manager, C1 was not given a prescribed medication on 3/12/22 which poses an immediate risk to the health and safety of the clients in care.
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Facility will follow up by submitting training materials and a roster of attendees by 4/5/22.

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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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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