496803832-12-2-2022-21-AS-VBEI-CLQVRM-20221202154009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:40:25 PM

Document Has Been Signed on 12/02/2022 03:40 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:	CALIFORNIA MENTOR-CALISTOGA HOME		FACILITY NUMBER:	496803832
ADMINISTRATOR:	RAY, MORGAN		FACILITY TYPE:	735
ADDRESS:	5302 BADGER RD		TELEPHONE:	(707) 538-9684
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY: 4		CENSUS: 4	DATE:	12/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Administrator, Morgan Ray		TIME COMPLETED:	03:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Morgan Ray. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and answering standard Covid-19 screening questions. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility around 2:40pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility continues to screen staff and clients and maintains documentation.

Facility has a designated visitation area outside and is allowing for visitation in client rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been N95 fit tested. LPA and Administrator discussed visitation and activities.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, gloves and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced June 2022. Facility has a fire system (which includes Carbon Monoxide detectors) that is maintained and monitored by a vendor. The most recent service was conducted January 2022.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CALIFORNIA MENTOR-CALISTOGA HOME	FACILITY NUMBER: 496803832
	VISIT DATE: 12/02/2022

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Continued from LIC809C

Administrator and LPA discussed their Emergency Disaster Plan, Mitigation Plan and Infection Control Plan.

LPA is also following up on a medication error for four clients that occurred in October 2022. Facility is using an agency to assist with staffing and a staff from the agency forgot to pass medication. The facility directed the agency that the individual was no longer permitted to work at the facility. Clients did not have any adverse affects to missing their medication.

Licensee/Administrator to submit updates of the following documents by 1/02/2023:

LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)

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.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/02/2022 03:40 PM - It Cannot Be Edited

Created By: Victoria Bertozzi On 12/02/2022 at 03:07 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: CALIFORNIA MENTOR-CALISTOGA HOME	FACILITY NUMBER: 496803832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)

80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four out of four clients which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2022
	Plan of Correction
1 2 3 4	Cleared during inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Victoria Bertozzi

LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022

LIC809 (FAS) - (06/04)

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