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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804140
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:52:52 PM

Document Has Been Signed on 03/17/2025 03:52 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: 4DATE:
03/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:51 PM
MET WITH:Domonique Thomas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced at this facility to open a complaint investigation pertaining to complaint 21-AS-20250307140033. LPA met with Administrator Domonique Thomas.

During investigation, Admin advised LPA that resident (R1) has been picking up their own prescriptions from the pharmacy and that the Admin did not know where R1's prescription for Buspirone 5mg was as a result. LPA observed medication to be listed on the Centrally Stored Medication log but not present in the medication drawer for R1. LPA reviewed R1's physician report which states that they cannot administer or store their own medication. Additionally, Admin advised that R1 has not been taking their medication but could not produce refusal documentation that was complete and current. LPA advised that for residents that cannot administer or store their own medication that she is responsible for every aspect of administering and storing the medication (deficiency cited, see 809D)

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: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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 03/17/2025 03:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/17/2025 at 03:00 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: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2025
Section Cited
CCR
80075(b)

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80075 Health Related Services(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section
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Facility Admin to self-certify on a LIC9098 that they will store and adminsiter all medications for residents that cannot store and adminsiter their own medications.
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cited above in that LPA and Admin observed medication listed on Centrally Stored Medication Log missing from R1's stored medications, which poses an immediate health, safety or personal rights risk to persons in care.
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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