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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:46:10 PM

Document Has Been Signed on 04/14/2022 12:46 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: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:
04/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Eryn Lugger (Residential Counselor)TIME COMPLETED:
01:01 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Eryn Lugger (Residential Counselor). Administrator, Shanice Moore was not able to come to the facility but was available by phone and gave authorization to staff to sign the report. 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 4/11/22 involving Client (C1). On 4/8/22 at around 3:07pm House Manager noticed on the bubble pack that the Risperidone 2mg tablet was still there for the day before 4/7/22 that was supposed to be provided to C1. It was also discovered that medication Lithium Carbonate 300mg was not in the bubble pack. CSU (Physician) was contacted for medical guidance and was advised to continue medication regimen. House Manager notified facility Administrator and responsible parties. Staff (S1) was inquired by House Manager about missing medication and was placed on immediate suspension, removed from shift for a week and won't be assisting clients with medications. Per incident report, staff will receive training and supervision for two weeks. However, there was another incident that occurred on 3/29/22 about missed dosage with same staff and facility provided as a proof of correction a policy indicating how the facility will provide training to staff on medication management and records of the training were also submitted to CCL. Based on incident report received on 4/11/22 the facility is not following their program plan dated 3/29/22.

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.
**Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 3/29/22.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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 04/14/2022 12:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/14/2022 at 12:21 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: HOPE HOUSE
FACILITY NUMBER: 496803657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
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 will ensure clients are assisted with their medications when needed. Administrator will designate another staff to assist clients with their medications as prescribed by their Physician and will submit staff schedule including designated staff to CCL by POC due date.

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Based on records review of facility self-incident report dated 4/11/22 and interviews conducted on 4/14/22 with Residential Counselor, C1 was not given a prescribed medication on 4/8/22 which poses an immediate risk to the health and safety of the clients in care.
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 **Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 3/29/22.

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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: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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