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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:17:33 PM

Document Has Been Signed on 06/12/2024 04:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VINCENT, THEFACILITY NUMBER:
216804010
ADMINISTRATOR/
DIRECTOR:		SAM FAYEFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 243-3959
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 126CENSUS: 70DATE:
06/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Executive Director, Sam Faye and Regional Health and Wellness Director, Roschelle FactorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 70 residents in care and 23 staff members on-site.

At approximately 9:25AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPA reviewed staff files. LPA observed that some staff did not complete their annual 2023 training (see LIC809D, Health and Safety Code, 1569.625(b)(2)). LPA reviewed First Aid/CPR certifications. LPA observed that medication technicians had appropriate certification. Direct Care Staff had first aid certification but it was not through a qualified medical agency. LPA received documentation regarding the first aid training that direct care staff received (see LIC9102, Health and Safety Code, 1569.618(c)(3)). LPA reviewed medications. LPA discussed with management regarding centrally stored medication and ensuring that it is written correctly in their central storage log (see LIC9102, regulation 87465(h)).

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. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator, and Regional Health and Wellness Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 04:17 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 06/12/2024 at 03:43 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: VINCENT, THE
FACILITY NUMBER: 216804010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Licensee did not comply with the section cited above. Licensee did not ensure that 5 of 11 staff completed their annual 2023 training. This poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee to submit a written plan outlining how they will ensure that annual training is completed timely for each employee. Licensee to submit documentation to support plan such as a training checklist. Plan and supporting documents to be submitted to CCL by POC due date of 06/22/2024 for review and approval.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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