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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 08/13/2024
Date Signed: 08/13/2024 12:30:33 PM

Document Has Been Signed on 08/13/2024 12:30 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 HOMEFACILITY NUMBER:
496803832
ADMINISTRATOR/
DIRECTOR:		SARAH LUCASFACILITY TYPE:
735
ADDRESS:5302 BADGER RDTELEPHONE:
(707) 538-9684
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:19 AM
MET WITH:Sarah Lucas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At approximately 11:15am, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and met with Administrator Sarah Lucas.

On 7/25/2024 CCL received an incident report for medication error that occurred on 7/24/2024. The Incident report states that at approximately 2:30pm nurse was preparing 3:00pm medication pass and noticed that the AM medications for resident (R1) were still present. Nurse immediately notified R1's physician, physician responded later that day and advised that medications can be resumed tomorrow. R1 placed on monitoring for adverse effects from missed medications. Missed medications identified as 3.5 scoops of fiber powder, 125mg of calcium carbonate, 2000IU of Vitamin D, 8.6mg of Senna, and 17g of Polyethylene Glycol.

LPA verified with Administrator that AM staff (S1) was immediately suspended form administering medications. Additionally, all staff will receive training on medication management. R1 did not experience any adverse effects and there were no changes observed in their condition as a result of the missed medication.

Per Administrator, the facility conducts training on medication management on an on-going basis, but has not conducted training after this incident occurred. Facility will conduct training on medication management as part of plan of correction.

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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 08/13/2024 12:30 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/13/2024 at 11:39 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: CALIFORNIA MENTOR-CALISTOGA HOME
FACILITY NUMBER: 496803832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted...with self-administration of prescription and nonprescription medications.

This requirement was not met by licensee as evidenced by:
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Facility to submit to CCL plan to conduct staff training on medication management by plan of correction due date. Training to be completed no later than 8/27/2024. Admin to submit updated LIC500 and DSP letters for all staff identified as DSP.
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Based on Incident Report, R1 was not given their medication as prescribed. This poses an immediate health, safety or personal rights risk to residents in care.
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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