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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:16:57 PM

Document Has Been Signed on 07/11/2022 12:16 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:
07/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Eryn Lugger (Residential Counselor)TIME COMPLETED:
12:15 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 6/28/22 involving Client (C1). Per incident report, On 6/27/22 at approximate 7:20pm at Hope House staff through medication cycle we had received today and noticed that C1's Clozapine 100mg wasn't with the rest of the medication cycle. "We were supposed to get it. C1 had finished the ones on-site for this morning with AM medications. Staff called Program Manager to inform them about missing medication. C1's physician's and responsible parties were notified. Per Physician's instruction C1 was fine because they received their morning dose 200mg, but to make sure that am dosage was not missed. Administrator picked up the medication on 6/28/22 at approximate 9am delivered to the facility and C1 was provided with their AM regular medication. During today's visit, Administrator notified LPA that C1 is required to have lab work done every 28 days per doctor's order then their physician has to review their results to prescribe Clozapine 100mg medication which is not refillable unless they receive prior doctor's approval. Per client records, C1 had their last blood drawn on 6/21/22 usually the prescription gets filled within a day, but this time the pharmacy didn't have the prescription ready on time due to doctor's order was not received yet.
No deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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