<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803828
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:52:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:RINCON VALLEY GUEST HOMEFACILITY NUMBER:
496803828
ADMINISTRATOR:POPAT, SABRINAFACILITY TYPE:
740
ADDRESS:996 ESTES DRTELEPHONE:
(707) 539-6247
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
08/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sabrina Popat, LicenseeTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Lopez and Cuadra arrived unannounced to conduct a case management visit. The case management visit was in regards to cite deficiencies discovered during a complaint investigation and met with staff Marlene Guido and Licensee, Sabrina Popat arrived later. LPAs conducted a risk assessment call prior to visit and spoke with Licensee, Sabrina Popat.

LPAs learned through interviews on 7/29/21 with Licensee and Administrator, the facility staff is not following their Dementia Plan dated 4/29/19 which states that “In accordance to Title 22 Section 87705, Care of persons with Dementia, we will maintain compliance. Item #5 Each dementia resident will have an annual medical assessment and reappraisal done”. Based on records review of (R1) Physician report dated 12/30/2019 with a diagnose of Dementia and blank LIC625 dated 2/28/20 that revealed that Resident (R1) has not been assessed for an updated care plan as stated on facility’s Dementia Care Plan. LPA conducted confidential interviews with staff and Licensee it was confirmed that R1 has not been assessed per CCL regulation within the last 12 months.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: RINCON VALLEY GUEST HOME
FACILITY NUMBER: 496803828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons w/Dementia (c) Licensees who accept...residents with dementia shall be responsible for ensuring...: (5) resident w/dementia shall have an annual Medical Assessment & reappraisal done at least annually....This requirement has not been met as evidence by:
8
9
10
11
12
13
14
Based on records review and interviews Licensee did not ensure that R1 had a medical assessment and re-appraisal done within 12 months as stated in facility’s Dementia Care Plan which poses a potential risk to health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2