486803637-9-1-2022-21-AS-DTOA-CHUQ3N-20220901114901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803637
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:49:13 AM

Document Has Been Signed on 09/01/2022 11:49 AM - 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:	ROSEWOOD CRISIS RESIDENTIAL		FACILITY NUMBER:	486803637
ADMINISTRATOR:	NATALIE LEE		FACILITY TYPE:	772
ADDRESS:	508 ALABAMA STREET		TELEPHONE:	(510) 415-4672
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	16	CENSUS: 13	DATE:	09/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Natalie Lee, Administrator		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Natalie Lee. The facility currently provides care for 13 clients all of which were present with two clients being discharged today. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. LPA measured water temperature at faucets accessible to clients. Water temperature measured between 112.5 and 116.7 degrees F, which is within regulation between 105 and 120 degrees F. Multiple fire extinguishers were located throughout the facility and all found to be last charged on 1/7/2022 at the time of the visit. Fire Inspection expired 6/4/2022 but facility will be requesting for an updated inspection and provide CCLD with the updated documentation. There was a sufficient supply dishes, silverware and both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room, kitchen, offices and supply closets located throughout the facility. There was a supply of hygiene products and paper products available. All client bedrooms have lighting & appropriate furnishings. Smoke detectors and carbon monoxide detectors located in facility hallways were tested and found to be in working order. The downstair secured basement area is currently utilized for client one-on-one program, support and appointments as well as staff offices. LPA conducted a review of staff training and found that all staff have current CPR and 1st Aid certification. Upon inspection LPA observed one over the counter medication located in client bedroom dresser. Medication was immediately removed and secured. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROSEWOOD CRISIS RESIDENTIAL	FACILITY NUMBER: 486803637
	VISIT DATE: 09/01/2022

NARRATIVE

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Infection Control:
Facility will be submitting an Infection Control Plan plan which will be reviewed. All clients and staff are vaccinated with no symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Visitation areas are located in the facility front porch. Staff are screened for temperature and symptoms on a daily basis and clients are screened based on observation and change of condition.

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

LPA requested the following documents be sent to CCL by COB 9/15/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Fire Clearance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/01/2022 11:49 AM - 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: ROSEWOOD CRISIS RESIDENTIAL	FACILITY NUMBER: 486803637
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81075(k)(1)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility did not comply with the section cited above in 1 out of 1 over the counter medications located in client bedroom drawer, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Administrator to ensure all medications, including over the counter medications and supplements, are locked and inaccessible to clients at all times Submit plan on how the facility will ensure all medications are centrally stored per regulations, and how the facility will enure future compliance with this regulation. POC due 9/2/22

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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