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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804140
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:19:12 PM

Document Has Been Signed on 10/02/2024 03:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FREMONT HOUSEFACILITY NUMBER:
496804140
ADMINISTRATOR/
DIRECTOR:		THOMAS, DOMONIQUEFACILITY TYPE:
735
ADDRESS:2120 FREMONT DRTELEPHONE:
(707) 542-1595
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Domonique Thomas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:33 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Domonique Thomas. Facility contact information was reviewed.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Admin advised home does not have air conditioning. LPA did observe fans present. LPA discussed possibly adding celing fans to residents' rooms in order to maintain compliance with regulation stating that the temperature cannot go above 85 degrees or be at least 30 degrees cooler than outside temperatures when experiencing extreme heat.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Resident (R1) does not have a bed present in their room. LPA asked R1 if they want a bed and R1 replied to LPA that mattresses are uncomfortable. R1 explained to LPA that they prefer to sleep on the floor. LPA advised Admin to obtain doctor note or note from case manager indicating no bed is desired by R1. Extra hygiene products and linens were available. LPA observed common hand towel in bathroom. LPA discussed with Admin that the use of common towels is prohibited. Admin will make paper towels available to residents rather than a hand towel. Water temperature in sink accessible to residents in care measured at 119.7 and 120 degrees F which is within the allowable range of 105 to 120 degrees F. LPA discussed with Admin the regulation pertaining to water temperature thresholds and that facility might consider turning down the water heater slightly so as to not go over 120 degrees F.



Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FREMONT HOUSE
FACILITY NUMBER: 496804140
VISIT DATE: 10/02/2024
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Continued from 809...

LPA and Admin observed numerous piles of animal feces present in all non-concrete areas of the backyard including spaces designated for resident activities. LPA and Admin observed fence about 5 feet high that borders perimeter fence to be in disrepair with protruding nails, which is a safety hazard to residents in care (deficiency cited, see 809D).

Fire extinguishers were not tagged but LPA observed them to be charged. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted 9/27/2024. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted a review of three [3] out of three [3] resident records. All three [3] residents R1, R2, and R3 did not have a physician's report on file (deficiency cited, see 809D).

At approximately 11:30am LPA conducted review of four [4] out of four [4]staff records. No deficiencies.

At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA and Admin discussed regulation regarding PRN medication administration record (MAR) and Centrally Stored Medication Log (CSML).

At approximately 1:30pm LPA and Admin reviewed cash P&I. LPA and Admin discussed cash ledger and maintaining records of monies received. Admin advised that facility does not manage the residents' money. They only cash the checks sent by regional center and give it to the resident. Admin will get receipt from bank when checks are cashed and store receipt with regional center check stub in respective residents' files.

Domonique Thomas Administrator Certificate 7028845735 is currently in pending renewal status. Licensing fees are due. LPA gave Admin LIS print out with PIN for online payment should they desire to pay online.



Continued on 809C(2)...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FREMONT HOUSE
FACILITY NUMBER: 496804140
VISIT DATE: 10/02/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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Document Has Been Signed on 10/02/2024 03:19 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/02/2024 at 02:54 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: FREMONT HOUSE
FACILITY NUMBER: 496804140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed numerous piles of animal feces present in all non-concrete areas of the backyard including spaces designated for resident activities. LPA and Admin observed fence about 5 feet high that borders perimeter fence to be in disrepair with protruding nails, which is a safety hazard to residents in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Facility to submit photos of repaired or removed fence by plan of correction due date. Facility to submit photos of yard free from animal feces by plan of correction due date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that three [3] out of three [3] residents did not have a medical assessment physician's report on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Facility to submit current physician's report for R1, R2, and R3 by plan of correction 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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


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