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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803839
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:59:00 PM

Document Has Been Signed on 06/22/2022 04:59 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:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Rhonel Recinto-CaregiverTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dina Alviso conducted Required 1-Year inspection and met with Caregiver Rhonel Recinto. The inspection is focused on the Infection Control procedures and practices of this facility.
Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator and caregivesr on duty had a mask on during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents.
Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. There were five (5) residents in care at the facility during this inspection. Fire extinguishers were current, serviced and tagged as required-expires 8/6/22.

LPA is requesting the following documents be updated and submitted to CCL by 6/29/2022: LIC308 - Designation of Administrator Responsibility, Updated Liability Insurance Certificate, 610 Updated Emergency Disaster Plan.
LPA observed the two staff on duty, live-in caregivers, Rhonel and Marlyn to not be wearing masks as required; The LPA was let into the home and never screened as required. LPA was not screened by either staff when arriving to the facility, and was let into the home no questions asked, no temperature taken. LPA observed medications accessible to residents in care in staffs unlocked bedroom. These violations will be cited, Personal Rights 87468.1(a)(2) and Administrator Qualifications and Duties, Care of Persons With Dementia 87705(f)(2)- 87405(d)(2) , 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 given
Exit interview conducted with the Administrator Estelita Guzman.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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 3
Document Has Been Signed on 06/22/2022 04:59 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/22/2022 at 04:14 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: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, staff did not screen the LPA when having them enter the facility or at any time once inside the facility, the licensee did not comply with the section cited above in the required screening of a visitor, which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Licensee to ensure that all STAFF and VISITORS are screened as REQUIRED before entering and/or being allowed into the facility. Submit how the facility will be in compliance and ensure that all visitors are screened as required, helping ensure health and safety/personal rights of residents in care -and being in compliance with requirements. POC due 6/23/22
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights 87468.1(a)(2)- Residents in assisted living.-ensuring personal rights are not violated at any time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations during the inspection. Caregivers Rhunel and Marlyn were not wearing face masks when the LPA arrived to the facility, and did not put a mask on, until the LPA asked the staff to put a mask on as required. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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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 regarding staff wearing masks as required, at all times. POC due no later than 6/23/22.
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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/22/2022 04:59 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/22/2022 at 04:30 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: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons With Dementia (f)(2)- The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation , medications accessible to residents in care. On staff's unlocked bedroom, staff had a weekly medication holder,, which held their daily medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Licensee to ensure that all medications, including staffs, are locked up and inaccessible to residents in care at all times. Licensee to hold an inservice with all staff, and submit how the facility will ensure all medications are inaccessible to residents at all times. POC due by 6/23/22.
Follow-up with proof of inservice medication training no later than 6/28/22.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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