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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:32:14 PM

Document Has Been Signed on 12/12/2023 12:32 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:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Shanice Moore (Administrator)TIME COMPLETED:
12:47 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Shanice Moore. Clients were observed having breakfast.

LPA initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathrooms measured at 109.4, 115.5, and 114.1 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Cleaning supplies are stored in a closet that was locked at time of inspection. Medications were reviewed, centrally stored and locked in the office. Fire extinguisher was last inspected April 2023. Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drills were conducted 11/26/23.

Three staff files and twelve client files were reviewed. Five out twelve client's care plan were not updated. One out of three staff do not have required First Aid and CPR certificates. Staff have required annual training hours. Administrator Certificate for Administrator Shanice Moore 6060870735, expired 10/25/2023. LPA confirmed ACS packet has been submitted, and re-certification is pending.

During file review, LPA/Administrator discussed the updated visitation and outing policy limiting client's visitations or requiring visitors to give 24-hour notice prior to arrival, which is not within Title 22 regulations regarding client's personal rights. Administrator agrees to review and ensure that all clients are given the right to have visitors each time the opportunity arises. Administrator will also update facility's visitation, outing policy and procedures regarding visitation and regulation 85072 that would require an update to the Admission Agreement and clients would need to agree to it.
Continued on LIC809C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HOPE HOUSE
FACILITY NUMBER: 496803657
VISIT DATE: 12/12/2023
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Continued from LIC809...

Facility contact information was reviewed, email address and phone number needs to be updated. Required postings observed. Facility does not currently handle cash resources.

Administrator to submit updates of the following documents by 12/22/2023:
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Control of property.

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. Appeal Rights Given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2023 12:32 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/12/2023 at 11:59 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: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, records review and interview with Administrator, the licensee did not comply with one out of three staff do not have an updated CPR training, which poses a potential health, safety risk to residents in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator to ensure that at least one staff on duty has CPR training at all times. Administrator to submit LIC 9098 self certification that all staff have been certified for CPR per regulation by POC due date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above in 5 out of 12 client's care plans have not been signed by the resident/responsible party within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator agrees to upgrade care plans with clients/responsible party to acknowledge and sign clients' care plans. Administrator to submit LIC 9098 self certification to CCL certifying that care plans had been updated by POC due date.
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: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2023 12:32 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/12/2023 at 12:09 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: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85072(b)(4)

85072 Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights. (4) To have visitors…visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interviews with Administrator, the facility updated visitation and outing policy limits client's visitations or requires visitors to give 24-hour notice prior to arrival, which is not within Title 22 regulations regarding client's personal rights, which is a potential health and safety risk to clients in care.
POC Due Date: 12/22/2023
Plan of Correction
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Administrator agrees to review and upgrade facility's visitation, outing policy, and procedures regarding visitation policy to ensure that all clients are given the right to have visitors each time the opportunity arises. Administrator will submit updated policy to the Department for review by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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