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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803657
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:44:58 PM

Document Has Been Signed on 12/19/2024 02:44 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/
DIRECTOR:		DEBBIE MCCULLOCHFACILITY TYPE:
735
ADDRESS:1550 N DUTTONTELEPHONE:
(707) 236-6696
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 12CENSUS: 10DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Shaelany Rios (House Manager)TIME VISIT/
INSPECTION COMPLETED:
02:59 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Stevenson arrived unannounced to conduct an Annual Required inspection and met with Administrator, Debbie McCulloch. Annual fees are current.

LPAs/staff initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature, Cleaning supplies are stored in a closet that was locked at time of inspection. Required postings were observed. LPAs/staff observed ramp blocked with caution tape and not being used due to moss/slippery (technical advisory issued). Client rooms were furnished per regulation. Extra hygiene products and linens were available. Medications were reviewed, centrally stored and locked in the office. Fire extinguisher was last inspected May 2024. Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drills were conducted 11/27/24. Water temperature in client bathrooms measured at 104 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. LPAs/staff observed bathroom #2 & 3 did not have tight-fitting covers on their containers (technical advisory was issued). 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. LPAs/staff noticed expired food located in the locked shed area. Per Administrator, the expired food is waiting to be discarded and show LPAs another food pantry area located in the garage where they keep their food stored per regulation. Also, LPAs/staff observed the refrigerator located in the kitchen had a lock and it was observed unlocked during the visit. Upon LPAs inquiring with staff, LPAs were informed that they do lock the refrigerator at night. LPAs had a conversation with Administrator and staff that snacks need to be made available for clients in care. LPAs observed fruits available in client's dining table.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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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: 12/19/2024
NARRATIVE
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Continued from LIC 809...

At approximate 12:00pm LPAs initiated file review of ten client's files and five staff files. All clients have medical assessments. However, ten out of ten resident's care plans have not been updated as stated per regulation. One out of five staff do not have required health screening including TB test on file (technical violation issued). Staff have required annual training hours.

At approximate 12:30pm, during the physical plant tour of the facility, LPAs were greeted by individual (I1) who was providing care and supervision to clients in care. However, it was revealed during file review that I1 was not associated with this facility, but it was associated and cleared to work in the sister facility. LPAs informed Administrator I1 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. ***Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance/transfer since December 2, 2024 for a total of $500. Administrator submitted required documentation to the Department to associate I1 to this facility.

Administrator Certificate for Administrator Debbie McCulloch 7016280735 , expired July 2024. LPA confirmed ACS packet has been submitted, and re-certification is pending. Facility contact information was reviewed. Facility does not currently handle cash resources.

Administrator to submit updates of the following documents by 12/27/2024: LIC 500 Personnel Summary, LIC308 Designation of facility responsibility, LIC 610 Emergency Disaster Plan (If changes)
and 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. Exit interview was conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2024 02:44 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/19/2024 at 02:21 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: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/Administrator observation, record review and interview with Licensee did not ensure to obtain a criminal record clearance for individual (I1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assesed for the amount of $500.
POC Due Date: 12/20/2024
Plan of Correction
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Administrator submitted required documentation to the Department to associate individual (I1) to this facility. I1 was cleared and associated to their sister facility. Administrator will submit a self-certification LIC9098 ensuring that regulation was understood to CCL 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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2024 02:44 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/19/2024 at 02:21 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: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 10 out of 10 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: 12/27/2024
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.
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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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