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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803639
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:50:13 PM


Document Has Been Signed on 11/15/2022 02:50 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:PEOPLE'S CARE CHARMIANFACILITY NUMBER:
496803639
ADMINISTRATOR:SEAWRIGHT, PATRICKFACILITY TYPE:
740
ADDRESS:5087 CHARMIAN DRTELEPHONE:
(951) 775-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:4CENSUS: 3DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Danah Fischer (DSP)TIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Danah Fischer. Administrator Patrick Seawright was not able to come to the facility, but was available by phone ang gave authorization for staff to sign the report. The inspection is based on Infection Control practices of this facility.

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility does perform daily screening of staff and residents and documents it in a binder. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. At approximate 2:30pm LPA/staff observed one out of one fire extinguisher was last serviced February 2021. Smoke Detectors and Carbon Monoxide detector were tested and operational. Last disaster drill was conducted on November, 2022.

Administrator will submit updates of the following documents by 11/28/22: LIC 308 Designated Administrator, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan, LIC400 affidavit regarding client cash resources and surety bond.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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Document Has Been Signed on 11/15/2022 02:50 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: PEOPLE'S CARE CHARMIAN
FACILITY NUMBER: 496803639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in 1 out of 1 fire extinguisher was not serviced since February 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit Proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department. POC due date
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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