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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804085
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:35:24 PM

Document Has Been Signed on 11/28/2023 02:35 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:ADULT DAY RESPITE PROGRAM, SANTA ROSAFACILITY NUMBER:
496804085
ADMINISTRATOR:LARKIN, JAKEFACILITY TYPE:
775
ADDRESS:490 MENDOCINO AVE STE 105TELEPHONE:
(707) 525-0143
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 15CENSUS: 6DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Stephanie Thueson (Coordinator) TIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting an Annual Required inspection and met with Coordinator, Stephanie Thueson. Participants were observed at Day Program engaged in activities. The Day program operates Tuesdays and Thursdays from 10am to 4pm.

LPA/Administrator initiated a tour of the facility at 11:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. The activity schedule for the day was written on a white board. The day program operates out of a primary room within the 490 Mendocino. Meals are provided by Meals on Wheels and contracts with the facility to serve participants. Participants have the choice to bring their lunch. Program maintains a supply of coffee for snacks. There is one bathroom available for participant use. Bathrooms were equipped with grab bars to ensure safety. Toxins were inaccessible. Facility does not handle cash and medications. The facility does not provide transportation. The smoke alarm system is maintained by the building manager in 9/23. Most recent Disaster drill was conducted 10/16/23. Carbon monoxide was tested and operational. Water temperature in bathroom measured at 115 degrees F which is within allowable range of 105-120 degrees F.
-At approximate 11:20amLPA/Administrator observed fire extinguisher was last inspected July, 2022.

File review was initiated at 11:30am. Two staff files and five participant files were reviewed. Staff have required First Aid and CPR certificates. However, 2 out of 2 (S1 & S2) staff did not have 8 hours of annual training required hours. 3 out of 5 participant's (P1, P2 & P3) did not have an updated care plan. Also, 2 out of 5 participants (P2 & P3) diagnosed with dementia did not have a current medical assessment on file.

Administrator submitted updates of the following: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Emergency Disaster Plan (LIC610E).
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 Administrator & copy of report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 11/28/2023 02:35 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/28/2023 at 01:54 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: ADULT DAY RESPITE PROGRAM, SANTA ROSA
FACILITY NUMBER: 496804085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Administrator's observation review, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care. Facility fire extinguisher was last charge on July 2022.
POC Due Date: 12/05/2023
Plan of Correction
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Facility to ensure that fire extinguishers are checked and charged annually. Facility agrees to have fire extinguisher charged and submit proof of service to Department by POC due date.
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Administrator's observation, records review and interviews, the licensee did not comply with the section cited above in two out two staff (S1 & S2), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Facility will conduct required training hours with staff and will submit LIC9098 self-certification as proof of correction by POC due date.
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: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/28/2023 02:35 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/28/2023 at 01:54 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: ADULT DAY RESPITE PROGRAM, SANTA ROSA
FACILITY NUMBER: 496804085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 3 out of 5 participant's care plans were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator agrees to have participant's care plans updated and will send a self-certification form (LIC9098) by POC due date.
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 1 out of 5 participant's medical assessments were not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
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Administrator agrees to have participant's medical assessments on file and will send a self-certification form (LIC9098) by POC due date.
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: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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