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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 08/23/2022
Date Signed: 08/23/2022 04:43:26 PM


Document Has Been Signed on 08/23/2022 04:43 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:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:ALEXANDER VARSHAVSKYFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 22DATE:
08/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Licensee Julia LatifiTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management inspection and met with Licensee, Julia Latifi. The purpose of this case management inspection is to follow up on citations given at annual inspection on 8/9/2022 and two self reported incident reports submitted to Community Care Licensing (CCL) 8/22/2022.

CCL received a self reported incident report reporting on 8/20/2022 after dinner, resident (R1) had an unwitnessed fall and was found on the floor next to R1's vomit. R1 was sent out to the hospital. During today's inspection LPA was informed R1 was brought back to the facility the following day after tests confirmed R1 had a UTI and was given antibiotics and R1 is back at baseline.

LPA obtained additional information regarding a second self reported incident report reporting also on 8/20/22 at 9:30PM caregiver was conducting last shift round and checked on R2, diagnosed with dementia. Caregiver found blood in R2's brief's. R2 was seen at the ER where irritation on upper inner thigh area was found, which R2 had been scratching. Anti itch cream was prescribed and R2 returned to the facility the next day. R2 is back at baseline.

LPA was following up on citations given for staff not being associated to facility at annual visit. LPA reviewed personnel list for the day, 8/23/2022 and all staff are cleared and associated to the facility.

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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