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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804155
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:15:37 PM

Document Has Been Signed on 01/24/2025 03:15 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:HE&RT LLCFACILITY NUMBER:
496804155
ADMINISTRATOR/
DIRECTOR:		NG, ERICAFACILITY TYPE:
734
ADDRESS:5679 QUEEN ANNE DR.TELEPHONE:
(707) 479-0276
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Administrator Erica NgTIME VISIT/
INSPECTION COMPLETED:
03:29 PM
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Licensing Program Analysts (LPAs) Christi Coppo and Ali Deniz arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Erica Ng. Facility contact information was reviewed.

At approximately 9:30am LPAs 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. Kitchen drawer with sharp knives locked. Kitchen pantry containing resident snacks was locked. LPAs and Admin discussed ensuring snack pantry remains unlocked and accessible to residents. Admin agrees to keep snack pantry unlocked. Admin advised LPAs that dishwasher has been broken for about a week.

LPAs advised Admin of regulation 80076 Food Services (a)In facilities providing meals to clients, the following shall apply: (20) All dishes and utensils used for eating and drinking and in the preparation of food and drink, shall be cleaned and sanitized after each usage.(A) Dishwashing machines shall reach a temperature of 165 degrees F (74 degrees C) during the washing and/or drying cycle to ensure that dishes and utensils are cleaned and sanitized. Admin agrees to either repair or replace dishwasher by no later than 2/3/25. Admin also agrees to use paper plates and cups until dishwasher is fixed and wash the pots and pans using water heated to 165 degrees F.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 107.3 degrees F in the main bath, 105.8 degrees F in shower room #1, and 108.7 degrees F in the kitchen which are all within the allowable range of 105 to 120 degrees F.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HE&RT LLC
FACILITY NUMBER: 496804155
VISIT DATE: 01/24/2025
NARRATIVE
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Continued from 809...

Fire extinguishers were last inspected 3/23/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 1/5/25. Facility has a backup generator for use during a power outage.

LPAs and Admin observed broken face plates in the main hall, shower room #1, and resident room #1. Admin agrees to replace all faceplates by no later than 2/7/25. Additionally, LPAs and Admin observed two [2] laminate floor planks in resident room #2 that need to be repaired/replaced to mitigate tripping hazard. Admin agrees to submit to CCL a plan to have laminate floor planks replaced by no later than 2/3/25.

LPAs and Admin discussed providing a shaded outdoor activity area for residents. Admin agrees to purchase/provide gazebo for shaded area.

At approximately 11:00am LPAs conducted a review of four [4] resident records. All required documentation present.

At approximately 11:30am LPAs conducted review of 5 [five] staff records. Health Screen present for staff (S1) however TB clearance not checked or indicated on Health Screen and chest xray not present. (deficiency cited, see 809D).

At approximately 12:45pm LPAs conducted review of P&I monies. Receipts present. No deficiencies.

At approximately 1:00pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in locked cabinets. LPAs observed the following errors:


Continued on 809C(2)...

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

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
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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: HE&RT LLC
FACILITY NUMBER: 496804155
VISIT DATE: 01/24/2025
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Continued from 809C...
  • Famotidine 20mg dosing instructions incorrect on Centrally Stored Medication Log (CSML) for R1. AM and PM dosing instructions on bubble pack were separated out on CSML, for each respective administration time; however quantity of tablets to be administered not adjusted down to match separated dosing instructions.
  • Docusate Sodium 100mg dosing instructions incorrect on Centrally Stored Medication Log (CSML) for R2. AM and PM dosing instructions on bubble pack were separated out on CSML, for each respective administration time; however quantity of tablets to be administered not adjusted down to match separated dosing instructions.
  • Prescribing physician for R2's Docusate Sodium 100mg bubble pack listed incorrectly on CSML. Physician should have been P2 but was listed as P1.

Deficiency cited for the above two [2] errors observed on the CSML (deficiency cited, see 809D).

Erica Ng Administrator Certificate 7011330735 expires 4/10/2026. All fees are current as of this time.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

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 Admin. 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: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2025 03:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/24/2025 at 02:34 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: HE&RT LLC
FACILITY NUMBER: 496804155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(7)(C)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (C) The drug name, strength and quantity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPAs and Admin observation and record review, the licensee did not comply with the section cited above in that Famotidine 20mg dosing instructions incorrect on Centrally Stored Medication Log (CSML) for R1. AM and PM dosing instructions on bubble pack were separated out on CSML, for each respective administration time; however quantity of tablets to be administered not adjusted down to match separated dosing instructions. Docusate Sodium 100mg dosing instructions incorrect on Centrally Stored Medication Log (CSML) for R2. AM and PM dosing instructions on bubble pack were separated out on CSML, for each respective administration time; however quantity of tablets to be administered not adjusted down to match separated dosing instructions, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Facility to submit plan to conduct training for all staff administering medication to residents. Training to be conducted on proper documentation procedures protaining to the Centrally Stored Medication Log by plan of correction due date. Facility to submit training log to CCL by no later than 02/14/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2025 03:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/24/2025 at 02:34 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: HE&RT LLC
FACILITY NUMBER: 496804155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPAs and Administrator observation and record review, the licensee did not comply with the section cited above in that S1 did not have TB clearance on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Facility to submit TB clearance for S1 by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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