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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:43:10 PM

Document Has Been Signed on 07/22/2022 02:43 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:CALIFORNIA MENTOR-CALISTOGA HOMEFACILITY NUMBER:
496803832
ADMINISTRATOR:CLEARY, CHARLENEFACILITY TYPE:
735
ADDRESS:5302 BADGER RDTELEPHONE:
(707) 538-9684
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
07/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Morgan Ray (Program Director)TIME COMPLETED:
02:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Morgan Ray (Program Director). LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

During today's visit LPA is following up on four incident report received at CCL on 7/6/22 involving all four Clients in care (C1, C2, C3 and C4). On 6/2/22 at around 9:00am Nurse Supervisor discovered that on 6/1/22 temporary staff (S1) who is a LVN from Nurse Registry did not assist four out of four clients with their prescribed medications between 11:00am to 7:00pm. Upon discovery of missed medications clients Physicians were notified and instructed to observe and monitor clients for any adverse reactions. Nurse Supervisor observed that medications were still in the medication containers and were not given to clients in care. S1 was terminated on 6/2/22 and Nurse Registry was notified about this incident.

During today's inspection, LPA was informed that S1 was a temporary staff who came to work for this facility
since the last weekend of May and did not receive training on medication management. Per Morgan, the facility has been conducting training to staff that pass out medications. However, the facility is not able to provide proof of staff training records for this year. LPA was also provided with staff schedule that reflects two staff (DSP/LVN) working between 5:30am-8:00am then clients do attend to day program during the day, two staff (DSP/LVN) between 12:00pm-2:00pm, two staff (DSP/LVN) between 2:00pm-8:00pm and one staff for NOC shift. Facility records (MARs) indicates that clients were provided with medications on 6/1/22. However, all recorded medications were found in their original container by Nurse Supervisor. According to Morgan, S1 had access to all clients medications and the reason why the clients were not assisted with their prescribed medications is unknown.
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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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Document Has Been Signed on 07/22/2022 02:43 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 07/22/2022 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: CALIFORNIA MENTOR-CALISTOGA HOME
FACILITY NUMBER: 496803832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2022
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription & nonprescription medications. This requirement had not been met as evidence by:
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Administrator/Program Director will ensure clients are assisted with their medications when needed. Administrator/Program Director are to schedule and provide a medication management training with staff that handles medications by POC due date 7/23/22.

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Based on records review of facility self-incident report dated 6/3/22 and interviews conducted on 7/22/22 with Program Director, 4 out of 4 clients (C1, C2, C3 & C4) were not given all their prescribed medication on 6/1/22 by S1 which poses an immediate risk to the health and safety of the clients in care.
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Facility will follow up by submitting staff training records by 8/12/22.

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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: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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