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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803766
Report Date: 10/25/2022
Date Signed: 10/25/2022 09:38:18 AM

Document Has Been Signed on 10/25/2022 09:38 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:AZALEA HOUSEFACILITY NUMBER:
236803766
ADMINISTRATOR:AYALA, ALMIDAFACILITY TYPE:
740
ADDRESS:209 AZALEA CIRTELEPHONE:
(707) 964-4940
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 4DATE:
10/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Almida AyalaTIME COMPLETED:
09:45 AM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted to CCL on 10/24/2022. LPA met with Administrator Almida Ayala, reviewed records and interviewed staff. The incident was in regards to a medication error occurring on 10/22 and 10/23/2022. Client, C1, was prescribed an antibiotic to be taken for five days starting 10/20/2022. When staff were preparing medication on 10/24/2022, it was noticed there were three pills remaining, when there should have been only one. An investigation was conducted and found that the medication was missed because it was not in the normal bubble pack. Staff will be retrained on the medication administration procedures of the facility.

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.

This report was reviewed with Almida Ayala and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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 10/25/2022 09:38 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 10/25/2022 at 08:58 AM
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: AZALEA HOUSE
FACILITY NUMBER: 236803766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on
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Licensee will ensure all staff who deal with medication, receive refresher training. Training to be scheduled by POC date of 10/26, and evidence of completed training to be submitted to CCL by POC
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records reviewed, Licensee did not ensure client was assisted with medication as needed. This poses an Immediate Health, Safety or personal rights risk to clients in care.
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date of 11/18/2022.

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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:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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