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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:25:12 PM

Document Has Been Signed on 05/01/2025 02:25 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/
DIRECTOR:		MCCORLEY, MAKEYLIAFACILITY TYPE:
735
ADDRESS:5302 BADGER RDTELEPHONE:
(707) 538-9684
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 3DATE:
05/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH: Makeylia McCorley (Administrator)TIME VISIT/
INSPECTION COMPLETED:
02:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on a self-incident report dated 4/3/25 received by Community Care Licensing (CCL) regarding a medication error and met with Administrator, Makeylia McCorley.

Per incident report: "On 3/31/25 about 1am and 8am, staff (S1) missed two doses of client (C1) prescribed antibiotic (Cephalexin 250 mg per 5ml). C1 was monitored for any adverse medical reaction, but no further incidents happened. C1's physician was notified as well as responsible parties.

During today's visit, LPA requested C1's medication administration records (MARs) and staff training records. According to Administrator, the confusion started when someone (unknown) highlighted the MARs' 3/31/25 date leading to S1 to assume that C1 did not need to be assisted with that medication on that day, which resulted in C1 missed two dosages of prescribed 10-day antibiotic medication. Administrator provided LPA medication records with medication error and all staff training records dated 4/5/25 regarding physician's order, mentor medication policy and administration, maintaining accurate logs of MAR and medication error. Per records review, C1's physician discarded the medication due that medication was not helping C1 and new prescription was issued. No further incidents have happened.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. **Civil penalty assessed in the amount of $250 for repeated violation within 12 months**

Exit interview conducted with Administrator and copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/01/2025 02:25 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/01/2025 at 01:41 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: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2025
Section Cited
CCR
80075(b)

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80075(b) Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. ***This requirement not met as evidenced by:
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Administrator provided proof of medication training conducted with staff. Facility to review all resident's medication to ensure compliance with regulation and submit written policy/statement of further handling of medication to CCL by POC due date.
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Based on self-incident report the licensee did not comply with section above by not properly assisting C1 with Cephalexin 250 mg per 5ml resulting in C1 missed two doses of prescribed medication, which poses an immediate health, safety or personal rights risk to persons in care.
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**civil penaltiy assessed in the amount of $250 for repeated violation within 12 months**

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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


LIC809 (FAS) - (06/04)
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