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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 08/05/2024
Date Signed: 08/05/2024 05:19:20 PM


Document Has Been Signed on 08/05/2024 05:19 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:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR:GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:9CENSUS: 8DATE:
08/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Estelita Guzman-AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Loera, conducted a continued annual inspection, on 8/5/24 at approximately 2:40pm, and met with Administrator/Licensee Estelita Guzman. Annual was started on 8/1/24, see LIC809.

Fire clearance is approved for nine (9) non-ambulatory, of which two (2) may be bedridden.
Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has a required infection control plan. The facility has an emergency disaster plan as required. Fire extinguishers were serviced and tagged as required.

LPAs reviewed six (6) resident files. LPAs reviewed four (4) staff files.

The following deficiencies were identified during file reviews:

Resident's (R2) medical assessment was not complete, many sections were left blank on many pages of the assessment. A note on a page of the LIC602 medical assessment referred the reader to see attached "problem list and medication list." These items were not observed attached to the medical assessment. Administrator couldn't provide the medical assessment documents to the LPAs for review.

This deficiency will be cited, 87458(a) Medical Assessment- Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment, see LIC809D.

Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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 4


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: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 08/05/2024
NARRATIVE
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Per file reviews, and staff interviews, Staff (S2) lacks a health screening chest x-ray or an intradermal test as required. S2 has been working for approximately six (6) months, per interviews.

This deficiency will be cited, 87411(f) Personnel Requirements – General- All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure, see LIC809D.

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.



Appeal rights were provided.
Exit interview conducted with the Administrator, Estelita Guzman.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/05/2024 05:19 PM - It Cannot Be Edited

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: FAMILY HOUSE
FACILITY NUMBER: 496803839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review and staff interviews, staff (S2) lacks a health screening chest x-ray or an intradermal test as required. S2 has been working for approximately six (6) months. the licensee did not comply with the section cited above] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee/Administrator to ensure staff S2 obtains a TB test and clearance as required by regulation. Submit copy of TB test and clearance (or chest x-ray) by POC due date 8/19/24.

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: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/05/2024 05:19 PM - It Cannot Be Edited

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: FAMILY HOUSE
FACILITY NUMBER: 496803839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record reviews, resident's (R2) medical assessment was not complete, many sections were left blank on many pages of the assessment. A note on a page of the LIC602 medical assessment referred the reader to see attached "problem list and medication list." These items were not observed attached to the medical assessment. Administrator couldn't provide the medical assessment documents to the LPAs for review. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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Licensee/Administrator to ensure a completed medical assessment is obtained for resident (R2) as required. Submit copy of medical assessment by POC due date of 8/26/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4