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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803358
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:05:58 PM


Document Has Been Signed on 10/20/2022 02:05 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:HOLY SPIRIT RESIDENTIAL CARE HOME INC. IIFACILITY NUMBER:
236803358
ADMINISTRATOR:GONZALEZ, PERLAFACILITY TYPE:
740
ADDRESS:1275 ELM STREETTELEPHONE:
(707) 972-5831
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:6CENSUS: 6DATE:
10/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Perla GonzalezTIME COMPLETED:
02:15 PM
NARRATIVE
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At approximately 12:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to a report of a medication error. LPA met with Administrator Perla Gonzalez, interviewed staff and reviewed records. Based on interviews conducted, R1 received another residents medication, in error, during morning medication administration. Staff contacted Administrator and responsible party. Resident physician was notified. R1 was monitored throughout the day. LPA learned of another incident where a resident required medical attention and 911 was notified on 10/13/2022. Licensee did not notify CCL of this occurrence.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal Rights given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/20/2022 02:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: HOLY SPIRIT RESIDENTIAL CARE HOME INC. II
FACILITY NUMBER: 236803358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2022
Section Cited

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87465 Incidental Medical and Dental Care:(a)(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on
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interviews conducted, staff gave another residents medication to R1. This poses an immediate Health and Safety risk to residents in care.
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date of 11/18/2022.
Type B
11/18/2022
Section Cited

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87211 (a)(1) Reporting Requirements: A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence... This requirement is not
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met as evidenced by: Based on interviews conducted, Licensee did not report a 911 call for a resident to CCL within 7 days of occurrence. This poses a potential Health, Safety or personal rights risk.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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