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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803796
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:02:38 PM

Document Has Been Signed on 05/21/2024 12:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WILLOW GLEN HOMEFACILITY NUMBER:
496803796
ADMINISTRATOR/
DIRECTOR:		FLORES INEZ M.FACILITY TYPE:
740
ADDRESS:4750 COUNTRY CLUB DRTELEPHONE:
(707) 708-2199
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH:Michelena Hernandez-CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a case management inspection, and met with caregiver Michelena Hernandez, who was the staff on duty.

The LPA was conducting a complaint investigation earlier today, 5/21/24, and the LPA observed that resident medications (R1-R2-R3-R4) were pre-poured into daily medi-set cases (five medi-sets) for a total of five (5) days, this is violation to regulation. Deficiency will be cited, 87465(h)(5) Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers, see LIC809D.

The following deficiency was cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties being assessed.

Complaint report signed by caregiver Michelena Hernandez, for Licensee.
A copy of the report, including appeal rights, were provided to staff for Licensee Zoe Teeter, and Administrator Inez Flores.
Bethany Moellers
Dina Alviso
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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 05/21/2024 12:02 PM - It Cannot Be Edited


Created By: Dina Alviso On 05/21/2024 at 11:41 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: WILLOW GLEN HOME
FACILITY NUMBER: 496803796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2024
Section Cited

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87465(h)(5) Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. This requirement was not met as evidenced by:
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LPA observed that resident medications (R1-R2-R3-R4) were pre-poured into daily medi-set cases (five medi-sets) for a total of five (5) days, this is violation to regulation. This is a risk to the health and safety of residents in care.
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submit plan of ensuring medications are provided to residents by qualified trained staff, and submit copy of LIC500 staffing schedule and list of staff that will be handling medications on each shift. POC due 5/22/24.

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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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
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