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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:17:02 PM

Document Has Been Signed on 10/19/2023 01:17 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: 6DATE:
10/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lita Guzman-AdministratoorTIME COMPLETED:
01:03 PM
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Licensing Program Analyst (LPA) Alviso conducted a case management on 10/19/23 at approximately 9:15am, and met with Licensee/Administrator Estelita Guzman.

Administrator Certificate, #6049702740, is current- expires 10/16/24. LPA observed two caregivers working at the time of arrival. There are currently six (6) residents in care.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required.

All renovation has recently been completed; Licensee is requesting an increase in capacity, from six (6) to nine (9) residents.

Fire clearance is approved for nine (9) non-ambulatory, which includes two (2) bedridden approval, effective 10/17/23. All exits were free and clear of obstruction. Fire extinguishers, (2), were serviced and tagged as required. LPA observed fifteen (15) smoke alarms, including carbon monoxide detector. All exit doors had auditory alarms, and the alarms were working properly during the inspection.

LPA toured the facility with the Administrator, the backyard needs to have the fencing completed, and gates that are self latching installed. LPA observed that as you step out of the exit door, there are two cement steps to your left, open and accessible off of the cement ramp, which is a health and safety hazard to residents in care. When the rail on the ramp ends, a cement walkway continues, and it is not level to the ground or to the dirt, so the edge has a drop that is a health and safety hazard for residents in care. Licensee stated they will ensure the above is completed in a timely manner to ensure health and safety of all residents in care. LPA obtained photos during the inspection.

Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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: 10/19/2023
NARRATIVE
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Licensee agreed to submit a written plan on how this exit door will be used. How staff will ensure the health and safety of all residents in care in regards to the exit door area, the open steps on the ramp, and the cement walkway with the large drop on the edge of the walkway to the ground. Licensee to submit when the self latching gates and fencing will be completed, this needs to be done in a timely manner for health and safety of all residents in care; Include this in the written plan. Ensure time frames of completion are listed, specifically on the fencing and the gates of the facility.

If the submitted written plan is sufficient, the Department may approve the capacity increase at that time. The LPA will notify Licensee after review of the written plan. If there is anything else needed, the Department will request it.

LPA observed the following deficiencies during the inspection:
LPA observed that there was a medication lock box in a small refrigerator that was not locked, and the key was hanging off the lockbox handle. This left the medications accessible to residents, and those not qualified to handle medications. This deficiency will be cited, 87465(h)(2)Incidental Medical and Dental Care- The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, 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.
Appeal rights were provided.
Exit interview conducted with the Administrator, Estelita Guzman.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 01:17 PM - It Cannot Be Edited


Created By: Dina Alviso On 10/19/2023 at 12:55 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87465(h)(2)

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87465(h)(2)Incidental Medical and Dental Care- The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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Licensee to ensure that all medications are locked and kept inaccessible to residents in care at all times. Hold an in-service with all staff on policy & procedures of medications. Submit proof of training by 10/25/23. Submit plan of correction, including scheduled date of training by 10/20/23.
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This requirement was not met as evidenced by: LPA observed that there was a medication lock box in a small refrigerator that was not locked, and the key was hanging off the lockbox handle. This left the medications accessible to residents, and those not qualified to handle medications. This is a risk to the health and safety of 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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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