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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 07/03/2023
Date Signed: 07/03/2023 05:36:59 PM


Document Has Been Signed on 07/03/2023 05:36 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: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:6CENSUS: 5DATE:
07/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Estelita Guzman-AdministratorTIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 7/1/23 at approximately 12:15pm, and met with Licensee/Administrator Estelita Guzman. Administrator Certificate, #6049702740, is current- expires 10/16/24. LPA observed three caregivers working at the time of arrival. There are currently five (5) residents in care.

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. Facility has an emergency disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on xxxxx. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements.

Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval. All exits were free and clear of obstruction. Fire extinguishers, two(2), were serviced and tagged as required, expires 8/11/23. LPA observed ten(10) of ten(10) smoke alarms, including carbon monoxide detector, all working properly during the inspection. All exit doors had auditory alarms, and the alarms were working properly during the inspection.

Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 116.4 F, which is within regulation. Medications were stored and locked making them inaccessible to residents. All toxins/cleaners were stored in locked cabinets, and inaccessible to residents in care. Administrator showed the new refrigerator/freezer that had been delivered this am. LPA requested the Administrator have staff transfer all frozen and refrigerated items, that were out, and stored in a plastic storage container, to help ensure the safety of food items being provided to residents.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 07/03/2023
NARRATIVE
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There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable for residents in care.

There are currently five(5) residents in care. LPA reviewed five(5) of five(5) resident files; All resident files were found to be complete.

LPA reviewed four(4) of four(4) staff files. LPA reviewed staff training. All four(4) staff have criminal record clearance, and are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 8/3/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Infection Control Plan-if any changes, as discussed
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond.
Copy of Current Liability Insurance
Copy of current Administrator Certificate

During the tour of the facility, the LPA observed some changes to the patio/deck area of the home. There is no railing/fencing, and no self latching gate on the patio/deck which is open on one whole side; LPA observed no railing or fencing which leaves an open drop to the cement ramp from the deck, and another smaller area of the deck with a drop to the dirt ground, with two drop down steps to it's right, all these areas are a safety hazard. This deficiency will be cited, -87705(h) Care of Persons with Dementia -Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents, see LIC809D.

Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 07/03/2023
NARRATIVE
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The LPA observed in review of facility records that the last emergency drills were done 1/27/2020 & 9/14/2020. The emergency disaster drills are to be done quarterly. This deficiency will be cited, H&S Code Emergency Plans15965.65(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, see LIC809D.

Deficiencies 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.

Exit interview conducted with the Administrator.
Appeal rights were provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/03/2023 05:36 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: FAMILY HOUSE
FACILITY NUMBER: 496803839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with the Administrator, and LPA's record review, the licensee did not comply with the section cited above in required emergency plan drills, last emergency drill were completed 1/27/20 & 9/14/20, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2023
Plan of Correction
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Licensee/Administrator to ensure that the facility conducts emergency disaster drills as required, Quarterly they are to be done & recorded, Licensee stated they will conduct a fire drill, document as required, and submit a copy to Licensing.Copy of the fire drill conducted, a drill on all shifts, will be submitted by 7/10/23. Plan of correction to be submitted by 7/4/23.
Type A
Section Cited
CCR
87705(h)
87705(h) Care of Persons with Dementia -Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), LPA observed the patio/deck to have areas with a drop to the ground and another with a drop to the cement ramp, there is no fencing, the ramp leads directly out to the front of the home and directly to a busy street, this a hazard to residents in care, the licensee did not comply with the section cited above in the facility backyard area and patio/deck, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2023
Plan of Correction
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Licensee/Administrator to secure and make safe the facility's backyard patio/deck as required by the regulations. Submit plan of correction to enclose the patio/deck, ensure a gate that can be open for use of the fire exit ramp, ensuring safety of residents in care/residents using this common area. POC due by 7/4/23, including a completion date(completed within 4 weeks). POC due 7/4/23.
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
LIC809 (FAS) - (06/04)
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