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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803876
Report Date: 06/01/2023
Date Signed: 06/01/2023 03:21:47 PM

Document Has Been Signed on 06/01/2023 03:21 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:
06/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:-Caregiver Pam WatkinsTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management to continue the Required- 1 Year visit, of 4/18/23; LPA conducted the continuation visit on 6/1/23 at approximately 9:15am, and met with caregiver Pam Watkins. There are five(5) residents in care. Caregiver Raffia arrived to the facility to help provide, to the LPA, facility records, including resident and staff records.

LPA received an updated LIC200 application form, and an updated facility sketch, for the change of capacity from six to five, as only one resident room will remain as a shared room, all others will be private. LPA will request a fire clearance inspection, and notify the licensee when the request is sent out.

Per review of the Fire/Disaster records, the last two evacuation fire drills were completed on 2/13/23 and 5/18/23.

The LPA is reviewing five(5) of five(5) resident files. The LPA is reviewing six(6) of six(6) staff files. All staff have required criminal record clearance

LPA observed that one(1) out of five(5) resident files was not on-site or available for review. Staff could not provide residents file to the LPA. This deficiency will be cited, 87506(b) (b) Each resident's record shall contain at least, all documents required by regulation, see LIC809D

Per LPA record reviews, staff had no training and/or had incomplete training. Staff #1, staff #2, staff #4, and staff #5, lack 20 hours of required completed training. Four(4) out of six(6) staff lack required training hours. This will be cited, H&S Code 1569.625(b)(2), see LIC809D.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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 5
Document Has Been Signed on 06/01/2023 03:21 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/01/2023 at 01:07 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in [3] out of [6] staff files, staff #1, staff #4, and staff #6 lacked current First Aid & CPR which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee to ensure staff obtain required First Aid and CPR training as required by regulation/H&S, staff #4 is obtaining this training today as they are currently on own, on shift days/nights at this time. All staff named above must obtain the above training(s) as required. Submit staff #4's training by tomorrow, 9am as they are on shift alone, 6/2/23; Submit all other staff by 6/9, unless working alone on shift, it must come before working on shift alone. Submit plan of correction by 6/2/23.
Type A
Section Cited
HSC
1569.69(b)
1569.69(b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in [4] out of [6] staff files, staff lacked eight(8) hours of required/completed medication training per H&S Code, which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee to ensure all staff obtain the required eight(8) hours of training and/or complete the required eight(8) hours of training, required for staff assisting residents with medicaton. Submit proof of staff's training, and plan of ensuring staff obtain required continued annual medication training in the future. Submit proof of medication training by6/23/23. Plan of correction due by 6/2/23.
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 Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/01/2023 03:21 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/01/2023 at 01:07 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in [1] out of [6] staff files, staff#6 had no file on-site for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Licensee to ensure that staff #6 has a complete file/record, all required hiring documentation as well as required trainings, on site as required by regulation. Submit written self-certification that this has been completed. POC due by 6/16/23
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in [4] out of [6] staff files, staff lacked 20 hours of completed required training hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee to ensure all staff obtain the required 20 hours of training and/or complete the required 20 hours of training, ensuring all staff have the annual training required for direct care staff. Submit proof of staff's training, and plan of ensuring staff obtain continued annual/all other trainings as required in the future. POC due by 6/30/2023.
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 Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/01/2023 03:21 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/01/2023 at 01:07 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record reviews, the licensee did not comply with the section cited above in one(1) out of five(5), resident #4 lacked a file on-site, available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee to ensure that resident #4 has a complete file, admision docuemenst, and all other required documents per regulation, on-site and and available for review. Submit written self certification that there is a complete resident, #4, file on-site as required. POC due 6/12/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 06/01/2023
NARRATIVE
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Per LPA record reviews, staff #1, #4, and #6, lack current first aid per review of records. Three(3) out of six(6) staff lack current First Aid and CPR. Staff do work shifts alone at times, so both first aid and cpr are required. This will be cited, 1569.618(c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times, see LIC809D.

LPA observed that one(1) out of six) staff files was not on-site and/or available for review. This deficiency will be cited, 87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain all required documents, see LIC809D

LPA reviewed staff records, [4] out of [6] staff lacked eight(8) hours of required/completed medication training per H&S Code. This will be cited, 1569.69(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period, see LIC809D.

LPA are requesting the following documents be updated and submitted to CCL by 6/23/2023:

LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610 - Emergency Disaster Plan
Copy of Current Liability Insurance
Copy of current Administrator Certificate
Copy of updated Infection Control Plan-if any changes

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 caregivers Pam Watkins and Raafia Mazhar Chang. Appeal Rights left with caregiver, with a copy of the LIC809 facility report, to provide to the Licensee/Administrator Catherine Clark.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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