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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804042
Report Date: 01/10/2025
Date Signed: 01/13/2025 10:06:59 AM

Document Has Been Signed on 01/13/2025 10:06 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BICKFORD HOMEFACILITY NUMBER:
486804042
ADMINISTRATOR/
DIRECTOR:		GLEMAR MELOFACILITY TYPE:
740
ADDRESS:5083 BICKFORD CIRCLETELEPHONE:
(707) 344-2628
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Alma Corsiga, LicenseeTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
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At approximately 1:30 PM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff 1 (S1). Alma Corsiga, Licensee was contacted via telephone and arrived approximately 30 minutes later. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Three (3) residents were away from the facility either at Day Program or on a community outing and one (1) resident was present during today's inspection. Facility has a hospice waiver for two (2), with no hospice residents currently in care, and is approved for all non-ambulatory residents. Licensee informed LPAs that Administrator has changed to Angel Dean. LPAs informed Licensee of the need to submit this request to Licensing.

At approximately 2:00 PM, LPAs initiated a tour of the facility with Licensee and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. All residents live on the first floor of facility and Licensee's family lives on the second floor. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, paper products, and incontinent care briefs available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPAs advised Licensee to ensure the laundry room remains locked at all times when unattended since there are chemicals and cleaning supplies in the room. Facility has at least two days of perishable food and LPAs advised Licensee to increase the facility's supply of non-perishable foods to ensure facility can sustain all residents in care for 7 days in the event of an emergency. Additionally, LPAs observed at least five (5) instances of expired non-perishable foods, (see LIC809D). Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPAs observed the fence in the backyard on the left side of the facility to be damaged and falling down, (see LIC809D). LPAs advised Licensee to ensure the facility has a designated internet access device available for resident use to remain in compliance with regulation. Facility has internet available to residents in care and the phone was tested an operational.
Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BICKFORD HOME
FACILITY NUMBER: 486804042
VISIT DATE: 01/10/2025
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Continued from LIC809...

Facility's fire extinguisher was observed charged and was last serviced 2/2024. Smoke and Carbon Monoxide detectors were tested and were not operational during inspection, (see LIC809D).Facility conducts bi-annual disaster drills with the most recent drill was conducted 6/2024. LPAs advised Licensee that drills shall be conducted on a quarterly basis moving forward in order to remain in compliance with regulation. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 12/2024. LPAs observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. Facility does not have a back up generator. Licensee provided LPAs with a copy of the facility's current liability insurance.

At approximately 2:30 PM, LPAs reviewed four (4) staff files and four (4) resident files. Four (4) of four (4) staff files reviewed have all the required paperwork, proof of initial and current training hours completed, and proof of current First Aid and CPR training. One (1) of four (4) resident files reviewed have all the required paperwork. LPAs observed records for Resident 1 (R1) and Resident 2 (R2) to only have the admissions agreements present, (see LIC809D). Additionally, LPAs observed Resident 3 (R3) missing a signed and dated personal rights form in their record. Licensee states facility coordinates medical and dental visits for the residents and provides transportation to and from their appointments.

At approximately 3:45 PM, LPAs reviewed medications and medication records. Resident 4 (R4) was observed with an expired medication currently being administered, R2 was observed with medications pre-poured into a weekly pill container and extra medications not recorded on the centrally stored medication destruction log, and R3 was observed with an unmarked baggy of pills in their medication administration bin which Licensee states were supposed to be destroyed (see LIC809D). Facility's P&I records and monies are not maintained in compliance with regulation as Licensee states that resident cash resources are kept in the facility's business bank account and the facility's logs have not been updated since 6/2024 for one resident and since 9/2024 for another resident, (see LIC809D). LPAs informed Licensee that resident funds shall never be co-mingled with facility funds.

Required Change of Administrator Documents:
  • LIC 308 (Designation of Facility Responsibility)

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BICKFORD HOME
FACILITY NUMBER: 486804042
VISIT DATE: 01/10/2025
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Continued from LIC809C...
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative 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)

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • LIC400 - Affidavit Regarding Resident Cash Resources
  • LIC402 - Surety Bond


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.

Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/13/2025 10:06 AM - It Cannot Be Edited


Created By: Julie Florio On 01/10/2025 at 04:31 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: BICKFORD HOME
FACILITY NUMBER: 486804042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring that the facility's smoke and carbon monoxide detectors were operational which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
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Licensee to submit receipt proof that the facility's smoke and carbon monoxide detectors have been services and are in working condition to CCL by POC due date 1/13/2025.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as evidenced by R1 missing a centrally stored medication record (CSMR), R2 having medications not listed on the CSMR and medications pre-poured in weekly pill container, R3 had an unmarked baggy of pills in their medication bin, and R4 had expired medications in the medication bin which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
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Licensee to submit self-certification that they have brought the facility into compliance with regulation and will ensure medications and medication records are maintained in compliance moving forward to CCL by POC due date 1/13/2025.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/13/2025 10:07 AM - It Cannot Be Edited


Created By: Julie Florio On 01/10/2025 at 04:31 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: BICKFORD HOME
FACILITY NUMBER: 486804042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the backside fence on the left side of the house was observed to have been damaged and is falling down which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee to submit photographic proof that the backyard fence has been fixed to CCL by POC due date of 2/10/1025.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in at least five (5) instances of expired non-perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee will self certify that all expired have been discarded and that the facility will remain in compliance moving forward to CCL by POC due date of 2/10/2025.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/13/2025 10:07 AM - It Cannot Be Edited


Created By: Julie Florio On 01/10/2025 at 04:31 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: BICKFORD HOME
FACILITY NUMBER: 486804042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the records for Resident 1 (R1) and Resident 2 (R2) only have the admissions agreements present, and Resident 3 (R3) was missing a signed and dated personal rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee to submit self certification that all missing documents have been added to the residents files by POC due date of 2/10/2025.
Type B
Section Cited
CCR
87217(e)
87217 Safeguards for Resident Cash, Personal Property, and Valuables
(e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This does not prohibit the licensee from providing advances or loans to residents from facility money.
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 in ensuring that resident cash resources are not co-mingled with facility funds, that facility has a bond sufficient to cover the cash resources being handled for residents, and does not have current and accurate logs to reflect the cash on hand which poses a potential personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee to submit current and accurate P&I logs for each resident who has cash resources, proof that funds are no longer being co-mingled, a LIC402 surety bond in the sufficient amount to cover the cash resources being handled, and LIC400 affidavit stating how much money the facility will handle for residents to CCL by POC due date 2/10/2025.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


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