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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:38:12 AM

Document Has Been Signed on 03/07/2024 11:38 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:HOPE HOUSEFACILITY NUMBER:
496803657
ADMINISTRATOR:MOORE, SHANICEFACILITY TYPE:
735
ADDRESS:1550 N DUTTONTELEPHONE:
(707) 293-3138
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 12CENSUS: 12DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Rita Larson (Social Rehab Director)TIME COMPLETED:
11:53 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Rita Larson (Social Rehab Director).

During today's visit LPA is following up on an incident report received at CCL on 2/27/24 involving Client (C1). On 2/27/24 at around 9:00am staff (S1) noticed that C1 was given another client's medication cup (C2). Staff contacted immediately crisis stabilization unit for guidance. Staff notified facility Administrator and responsible parties. Per Rita, S1 was not paying attention and got confused due to having two clients with the same name. During today's visit, LPA observed that client's medications cups have their names on it and the cups are the same color. The facility terminated S1 immediately as of 2/27/24.

Also, LPA is addressing reporting requirements issue discovered during complaint investigation # 21-AS-20240201160245. LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. At the time of the investigation, the administrator could not provide proof that hospitalization of C3 was reported to CCL. LPA learned that the facility is going to submit a change in administrator. LPA is requesting documentation regarding a change of administrator to be submitted to CCL with the following:

Documentation Needed for Change of Administrator:
LIC 200 for change of administrator, LIC 501 Personnel Record, LIC 503 Health Screening Report - personnel, Copy of Administrator's certificate and Board Resolution stating who the Administrator is and that the board has approved of the individual.

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 conducted with Social Rehab Director and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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Document Has Been Signed on 03/07/2024 11:38 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/07/2024 at 11:00 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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
80075(b)(5)(B)

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80075(b) Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription... (5)...(B) Once ordered by the physician the medication is given according to the physician's directions.This requirement had not been met as evidence by:
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Licensee/Administrator will ensure clients are assisted with their medications as prescribed by their physician. The facility will submit a written plan how they will ensure that clients are assisted with their prescribed medication by POC due date.
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Based on records review of facility self-incident report dated 2/27/24 and interviews conducted on 3/7/24 with Social Rehab Director, C1 was given another's client prescribed medication on 2/27/24 which poses an immediate risk to the health and safety of the clients in care.
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Type B
03/15/2024
Section Cited
CCR80061(a)(1)(D)

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80061 Reporting Requirement (a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within 7 days of the occurrence of...(D)Any injury to any client which requires medical treatment. This requirement has not been met as evidence by
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Licensee to provide training to all care staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date.
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Based on interviews conducted, the Licensee did not comply with the section cited above and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.
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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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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