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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801028
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:08:52 PM

Document Has Been Signed on 01/17/2024 03:08 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DRAKE TERRACEFACILITY NUMBER:
216801028
ADMINISTRATOR:DONNA DANIEL-HERRFACILITY TYPE:
740
ADDRESS:275 LOS RANCHITOS ROADTELEPHONE:
(415) 491-1935
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 130CENSUS: 113DATE:
01/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Assisted Living Director, Mary Ann De Lara, Resident Relations Director, Arlene Samonte, and Executive Director, Shawn MooneyTIME COMPLETED:
03:18 PM
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At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Residential Relations Director, Arlene Samonte, Assisted Living Director, Mary Ann De Lara, and Administrator/Executive Director, Shawn Mooney.

LPA reviewed resident medication records. Medication was found to be centrally stored and secure. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 12/04/2023. Report states that on 11/26/2023, Resident 1 (R1) was administered a medication that they did not have a prescription for. Resident was observed to not have any adverse effects. Facility made all appropriate notifications per regulation (this deficiency has been cited, see LIC809D, Regulation 87465(a)(4)). Facility conducted a in-service training covering Medication Related Errors and The Five Rights of Residents. LPA was provided with a copy of training documentation. LPA cleared deficiency cited today during visit.
LPA also cleared the previous deficiency cited conducted on 12/20/2023 for Health and Safety Code 1569.625(b)(2) during visit.

LPA was informed that the facility has a new Executive Director, Shawn Mooney. LPA and Executive Director discussed submitting Administrator paperwork to the Regional Office so they can be established as the Administrator on file. Until paperwork has been submitted, facility understands that Donna Daniel-Herr will continue to be the Administrator on file until paperwork has been reviewed and processed.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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: DRAKE TERRACE
FACILITY NUMBER: 216801028
VISIT DATE: 01/17/2024
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Continued from LIC809

LPA also requested for the following documents to be submitted:
Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)

Administrator documents to be submitted for Shawn Mooney by 02/01/2024. Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 02/16/2024.

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.

Exit interview conducted. Plan of Corrections reviewed and developed with Executive Director. Copy of report, LIC809D, Plan of Corrections, Plan of Correction Letters, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2024 03:08 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 01/17/2024 at 01:42 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: DRAKE TERRACE
FACILITY NUMBER: 216801028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by :
Deficient Practice Statement
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Based on document review, the Licensee did not comply with the section cited above. Resident 1 (R1) was administered a medication that they did not have a prescription for. This poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 01/18/2024
Plan of Correction
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Deficiency cleared during visit. LPA was provided with medication training documentation that was conducted on 11/27/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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