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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803876
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:58:46 PM

Document Has Been Signed on 04/14/2022 03:58 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:CWH SANTA ROSA, INCFACILITY NUMBER:
496803876
ADMINISTRATOR:CLARK, CATHERINEFACILITY TYPE:
740
ADDRESS:100 CREEK WAYTELEPHONE:
(707) 526-4400
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Catherine Clark-AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dina Alviso arrived unannounced to conduct a Required-1 Year inspection, and met with Licensee, Catherine Clark (Cathy). This inspection is focused on the Infection Control Procedures and Practices of this facility.

There were five(5) residents in care at the facility during this inspection. LPA observed a large entry side table by the front door, with sanitizer, thermometer, and covid 19 screening questions, to screen all staff and visitors. Residents are screened daily, and observed for any changes.

Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Fire extinguisher was serviced and tagged as required. Smoke Detectors, five(5), which are also carbon monoxide detectors, were found to be operational during the inspection. There was a sufficient supply of both perishable and nonperishable foods as required. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed.

Fire clearance for 5 non-ambulatory, which includes one bedridden approval; Fire clearance approved on 2/12/2020 by Inspector Marcia Belforte. Mitigation plan was received and reviewed by the Department. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff are to wear masks at all times. Administrator had a mask on during the inspection.
Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 03:58 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/14/2022 at 03:33 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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshall

This requirement is not met as evidenced by: LA's observation, a large garbage can was blocking the backyard fire exit gate.
Deficient Practice Statement
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Based on LPA's [(observation), the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty in the amount of $500 is assessed today.
POC Due Date: 04/15/2022
Plan of Correction
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Licensee to ensure that the fire exit gate is never blocked by any item from freely opening as required in ensuring the fire clearance is maintained as it was granted. Plan on how the facility will ensure the fire exit gate is never blocked and easily accessible in an emergency. POC due 4/15/22.
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: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876
VISIT DATE: 04/14/2022
NARRATIVE
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LPA observed the caregiver without a mask on as LPA was let into the home, the caregiver didn't put a mask on until the LPA asked the staff to put one as required. The LPA was not screened by the caregiver who let them into the facility as required. The backyard fire exit gate was blocked by a large garbage can. These three(3) deficiencies will be cited, see LIC809Ds. An immediate civil penalty in the amount of $500 is assessed today.

LPA are requesting the following documents be updated and submitted to CCL by 4/20/2022:

LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E - Emergency Disaster Plan
LIC999- Facility Sketch-Floor Plan
Copy of Current Liability Insurance
Copy of current Administrator Certificate
Copy of Updated Mitigation Plan

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. 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, Catherine Clark.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/14/2022 03:58 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/14/2022 at 03:16 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: CWH SANTA ROSA, INC
FACILITY NUMBER: 496803876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights 87468.1(a)(2)- Residents in assited living.-ensuring personal rights are not violated at any time.
This requirement is not met as evidenced by: LPA's observations during the inspection. Caregiver Bethany Clark was not wearing a face mask when the LPA arrived to the facility, and did not put a mask on, for approximately five(5) minutes, until the LPA asked the staff to put a mask on as required.
Deficient Practice Statement
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Based on LPA's [(observation) , the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Licensee to ensure the staff wear masks at all times as required, ensuring residents in cares personal rights and health and safety. Submit plan of correction of how the facility will be in future compliance regarding staff wearing masks as required. POC due no later than 4/15/22.
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: LPA's observations, staff did not screen the LPA when having them enter the facility or at any time once inside the facility.
Deficient Practice Statement
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Based on LPA's [(observation), the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Licensee to ensure that all STAFF and VISITORS are screened as required before enteing
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 of residents in care and being in compliance with requirements. POC due 4/15/22.
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: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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