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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803929
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:54:13 PM

Document Has Been Signed on 05/20/2022 12:54 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:MAGGIE'S CARE HOMEFACILITY NUMBER:
496803929
ADMINISTRATOR:GARCIA, MAGGIEFACILITY TYPE:
740
ADDRESS:916 RENEE COURTTELEPHONE:
(707) 293-9833
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Maggie Garcia (Licensee)TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Licensee, Maggie Garcia.

LPA learned through interviews on 5/10/21 with Licensee did not conduct required staff training with staff (S1) per regulation prior to provide care and supervision to residents in care. Based on records review and interviews with Licensee revealed that facility did not follow their AWOL policy and procedures about notify CCL by telephone no later than next working day after R1 eloped the facility.

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
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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 2
Document Has Been Signed on 05/20/2022 12:54 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/20/2022 at 11:30 AM
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: MAGGIE'S CARE HOME
FACILITY NUMBER: 496803929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2022
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) - Reporting Requirements - A written report shall be submitted to the licensing agency ...within 7 days of the occurrence of any of the events specified in (A) - (D). (D)Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by:
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Licensee to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Licensee agrees to sent a statement that regulation has been reviewed & state how the regulation will be complied with in the future; and send to CCL along with form LIC9098 by POC due date
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Based on LPA’s records review and interviews conducted Licensee did not ensure that CCL was notified of R1’s AWOL incident on 5/9/222 which poses an immediate health & safety risk to residents in care.
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Type B
06/03/2022
Section Cited
HSC1569.625(b)

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HSC §1569.625(b) Staff training; legislative findings…This requirement is not met as evidenced by:
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Licensee will ensure ALL staff will have training as required by Health & Safety Code. Licensee to submit LIC 9098 self-certification that all staff have been trained according to Health & Safety Code annually, and/or initial training to CCL by POC date.

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Based on records review & interviews with Licensee, the facility did not ensure that staff (S1) had required staff training prior to provide care and supervision to residents in care which poses a potential risk to the health and safety of the residents.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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