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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570317743
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:08:31 PM

Document Has Been Signed on 10/27/2021 12:08 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:DAVIS SUMMER HOUSEFACILITY NUMBER:
570317743
ADMINISTRATOR:MAIRA GURROLAFACILITY TYPE:
735
ADDRESS:2525 EAST 8TH STREETTELEPHONE:
5307571294
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 14CENSUS: 10DATE:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Maira GurrolaTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa (JN) arrived at Davis Summer House to conduct a Case Management visit regarding a self reported incident that was sent to CCL on 10/11/2021.
LPA spoke with Administrator, Maira Gurrola. It was reported that on 10/07/21 Resident (R1) reported that they had been menstruating, explaining "I haven't had my period since before my depo shot". Facility contacted R1's advice nurse and discovered R1 had missed prescribed Depo-Provera injection. Facility arranged for R1 to receive Depo-Provera injection on 10/11/21, at 1:10 PM. Her next injection has been scheduled for December and has been logged on facility's calendar

Administrator stated that each resident has an advocate assigned to help them access medical and dental appointments, and this particular appointment was mis-documented by previous advocate (who has since been reprimanded and removed from those duties), nonetheless Licensee failed to ensure that client/resident received necessary medical services.

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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 10/27/2021 12:08 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 10/27/2021 at 10:49 AM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: DAVIS SUMMER HOUSE
FACILITY NUMBER: 570317743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2021
Section Cited
CCR
80075(a)

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80075(a) Health Related Services. Licensee shall ensure that each client receives necessary...medical or dental services, including the arrangement for and or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee agrees to re-train all staff on the policies and protocols in best practices ensuring all residents receive the necessary medical and dental services required. Licensee to submit copy of training outline and signatures of all attendees as proof of correction by POC date 11/30/21, to LPA of Record.
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Based on record review, LPA found facility failed to provide transportation to services for required injection. This poses an immediate health and safety risk to clients 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:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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