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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:16:04 PM


Document Has Been Signed on 07/28/2022 02:16 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:ALTA CARE HOMEFACILITY NUMBER:
496804055
ADMINISTRATOR:MONTE, AIRA MELANIE V.FACILITY TYPE:
740
ADDRESS:96 ALTA DRIVETELEPHONE:
(707) 508-7634
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
07/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, David LockerbieTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with David Lockerbie, Licensee. The purpose of this case management inspection is to follow up on staff being associated to facility.

On 07/12/2022 LPA conducted Post-Licensing inspection of facility. LPA noticed a new staff member and inquired name. LPA was unable to locate name on guardian checklist and contacted Regional Office to confirm. Staff was just being associated that day. LPA discussed with Administrator that all individuals working, volunteering, living in the facility, must be background checked and cleared by DOJ along with associated to the facility prior to being at the facility. LPA completed inspection and left signed LIC809 & LIC809-C with directions to send Community Care Licensing (CCL) requested documents.

On 07/15/2022 LPA received requested document (LIC 500 Personnel Report) from facility, along with other requested documents. LPA was unable to locate Staff (S1) on guardian, called Administrator who informed, S1 is an employee at facilities sister facility and has been working at Alta Care Home since 07/18/2022. LPA checked with CCL and although S1 has been background cleared and is associated to other facility S1 is not associated to this facility. LPA explained to Administrator again, unless an individual is background cleared and associated to the facility, they cannot be there per regulations and then emailed Administrator Guardian Information to sign up to get account to complete associations and transfers. LPA checked Guardian, as of 07/28/2022 S1 is still not associated.

LPA confirmed S1 has cleared fingerprints in the system but is not and never was associated to this facility.

Immediate Civil Penalties are being assessed in the amount of $500 due to staff S1 not being associated to the facility.



*****Total Civil Penalties issued today in the amount of $500.00
Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided..

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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 07/28/2022 02:16 PM - It Cannot Be Edited

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: ALTA CARE HOME
FACILITY NUMBER: 496804055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited

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87355(e)(2) Criminal Record Clearance...Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
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Based on interview & record review Administrator didn’t comply w/section cited above in 1 out of 4 staff weren’t associated to facility which poses a potential health, safety or personal rights risk to persons in care. During visit on 7/28/2022 LPA observed staff S1 was working w/residents and not associated to facility this day.
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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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