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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800503
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:21:33 PM

Document Has Been Signed on 10/12/2023 04:21 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:SHALOM HOUSEFACILITY NUMBER:
216800503
ADMINISTRATOR:MARIA DEL PILAR DE OLAVEFACILITY TYPE:
740
ADDRESS:566 WAKEROBIN LANETELEPHONE:
(415) 491-0604
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 5CENSUS: 2DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Del Pilar De Olave, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by Administrator/Licensee Pilar. There is a total of 2 residents, none have a diagnostic of dementia and no residents currently on Hospice.

LPA toured the facility on 10/12/2023 at 9:10 AM with Pilar - licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 4/11/2023 at the time of the visit. Smoke detectors and carbon monoxide detector were found to be operational during the visit. Hot water temperature measured between 115 degrees F and 115.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 10/12/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked hallway closet. The bathrooms designated for residents at the facility were supplied with hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 10/12/2023.

A review of two resident & three staff records and licensee/administrator as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:00 AM on 10/12/2023 and learned that 2 of 2 residents have updated appraisals/needs & care plans and physician’s assessment (LIC 602A).



Medications were centrally stored in locked cabinet in the facility kitchen area, although some were pre-poured (TV given). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/12/2023. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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 10/12/2023 04:21 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/12/2023 at 12:50 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: SHALOM HOUSE
FACILITY NUMBER: 216800503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Administrator and record review, the licensee did not comply with the section cited above in 2 out of 4 staff files do not contain required health screening report or TB test verification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee to have Staff (S1) & (S2) obtain a health screening with TB test and submit copies to Community Care Licensing for review by POC due date 10/27/2023. Licensee to notify CCL if more time is needed.

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 Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 04:21 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/12/2023 at 12:50 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: SHALOM HOUSE
FACILITY NUMBER: 216800503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the administrator did not comply with the section cited above in 3 out of 3 staff do not initial training required and or on going training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Facility to ensure that all facility & agency staff have initial training required as well as on going training. Facility to provide CCLD with a plan on how facility will ensure that all staff have required training on file as well as how it will maintain the on going training and self certification that staff has all training required to be reviewed by the Department by POC date of 10/27/23 in order to clear this citation.

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 Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 04:21 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/12/2023 at 12:50 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: SHALOM HOUSE
FACILITY NUMBER: 216800503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the administrator did not comply with the section cited above in 1 out of 1 facilty quarterly disaster drills were not conducted which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator stated that there is no proof of drill, we have not been doing.
POC Due Date: 10/20/2023
Plan of Correction
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Facility to ensure that facility will conduct quarterly disaster drills as required by Health & Sfety Code. Administrator to submit to CCL proof of disaster drill conducted wiht the facility by POC date of 10/20/2023.
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 Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 04:21 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/12/2023 at 01:06 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: SHALOM HOUSE
FACILITY NUMBER: 216800503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having or aware that the facdility needs an Infection Control Plan which poses a potential health and safety risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Administrator will provide and Infection Control Plan to CCL no later than the POC date.
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the administrator did not comply with this section above due to Licensee's Administrators Certificate expired December, 2022. This regulation poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee shall provide WEEKLY updates regarding obtaining an updated Administrators Certificate. Furthermore, Licensee shall submit a plan for future compliance and an LIC 9098-Self Certification form.
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 Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 04:21 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/12/2023 at 01:47 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: SHALOM HOUSE
FACILITY NUMBER: 216800503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance- 87355(e)(1)- All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff associations list from Departments LIS Data Base, and review of DOJ Fingerprint Lists/Clearance Information in the Guardian website. Licensee stated to the LPA that she did not follow-up on Leticia Reye's fingerprinting documentation and/or ensure she had fingerprint clearance & has worked in the facility since 9/1/2023. This is a personal rights/Health and Safety violation and risk to all residents in care. An immediate Civil Penalty will be assessed in the amount of $500-see LIC421BG.
POC Due Date: 10/13/2023
Plan of Correction
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Licensee/Administrator to have the individual/Susan Nyambura get fingerprinted and obtain criminal record clearance. The individual can't return to work and/or be on facility premises until criminal record clearance is obtained and/or a criminal record clearance exemption is granted. Licensee/Administrator stated her understanding of the regulation and information stated above. Licensee to submit facility policy and procedures regarding hiring staff and fingerprint clearance requirements, and plan in ensuring compliance with the regulation. POC due 10/13/23.
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 Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


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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: SHALOM HOUSE
FACILITY NUMBER: 216800503
VISIT DATE: 10/12/2023
NARRATIVE
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LPA reviewed a sample of staff records 10/12/2023 at 11:00 AM and learned that 1 of 4 facility staff (S1) who require caregiver background checks have not received a criminal record clearances or exemptions and have been working at facility since 9/1/2023 (see LIC809-D & LIC421BG for $500 Civil Penalties). Direct care staff has no proof of annual training requirements for 2022/2023 on file (see LIC809-D). Facility also did not have proof of 2 of 4 staff’s Health Screening or TB test (see LIC809-D). Facility was able to present LPA with proof of CPR for 4 out of 4 staff & 1st Aid certifications for 4 out of 4 staff that files were reviewed. Maria Del Pilar de Olave Administrator Certification # 6030062740 expired on 12/7/2022 and has not renewed (see LIC809-D).

LPA reviewed Licensing Information System (LIS) with licensee/administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have not been conducted quarterly as required by Emergency and Preparedness Health & Safety Code. (see LIC 809-D) & or submitted required Infection Control Plan (LIC809-D)



Civil Penalties of $500 given for staff working at facility without obtaining background clearance for over 1 month.

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.

Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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: SHALOM HOUSE
FACILITY NUMBER: 216800503
VISIT DATE: 10/12/2023
NARRATIVE
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LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/31/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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