<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 11/03/2022
Date Signed: 11/03/2022 06:46:26 PM

Document Has Been Signed on 11/03/2022 06:46 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:
11/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:01 PM
MET WITH:Estelita Guzman-AdministratorTIME COMPLETED:
06:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alviso conducted a case management inspection, and met with Administrator Estelita Guzman.

This case management is being completed to cite deficiencies that were observed in a complaint inspection completed earlier today, 11/3/22. These deficiencies were unrelated to the complaint inspection.

LPA was not screened upon entry into the facility by staff that opened the facility door, and/or any other staff working in the facility, another caregiver and the Administrator. This will be cited, Administrator Qualifications and Duties- 87405(d)(2)-see LIC809D.

LPA observed the facility staff at the stove cooking and the staff had no mask on. Staff are to wear masks as required. This will be cited, Personal Rights 87468.1(a)(2)- see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies as required may lead to additional citations and civil penalties, including deficiencies re-cited within 12 months.
Exit interview conducted.
Appeal Rights Given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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 2
Document Has Been Signed on 11/03/2022 06:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/03/2022 at 06:14 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: FAMILY HOUSE
FACILITY NUMBER: 496803839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited
CCR
87405(d)(2)

1
2
3
4
5
6
7
Administrator Qualifications and Duties- 87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply: (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
1
2
3
4
5
6
7
Licensee to ensure that all STAFF and VISITORS are screened as REQUIRED before entering the facility and/or being allowed into the facility. Submit how the facility will be in compliance and ensure that all visitors are screened as required,
8
9
10
11
12
13
14
This requirement was not met as evidenced by: LPA's observations upon entering the facility, the staff didn't screen the LPA as required. This is a risk to health & Safety and/or to personal rights of residents in care.
8
9
10
11
12
13
14
helping ensure health and safety/personal rights of residents in care -and being in compliance with requirements. POC 11/4/22.
Type A
11/04/2022
Section Cited
CCR87468.1(a)(2)

1
2
3
4
5
6
7
Personal Rights 87468.1(a)(2)- Residents in assisted living.-ensuring personal rights are not violated at any time.
This requirement was not met as evidenced by: LPA's observation
1
2
3
4
5
6
7
Licensee to ensure the staff wear masks at all times as required, ensuring residents in care health and safety. Submit plan of correction of how the facility will be in future compliance
8
9
10
11
12
13
14
of a staff caregiver/cook not wearing a mask and cooking food in the facility kitchen.Staff are to wear mask in the facility at all times. This is a risk to health & Safety and/or to personal rights of residents in care.
8
9
10
11
12
13
14
 regarding staff wearing masks as required, at all times. POC due no later than 11/4/22..
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2