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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:06:28 PM

Document Has Been Signed on 12/06/2024 02:06 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:MC HUGH CARE HOMEFACILITY NUMBER:
490108000
ADMINISTRATOR/
DIRECTOR:		DIZON, TIFFANYFACILITY TYPE:
740
ADDRESS:1000 GORDON LANETELEPHONE:
(707) 545-8213
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 15CENSUS: 11DATE:
12/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rodrigo Gallardo (staff)TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Frank arrived unannounced for the purpose of conducting a case management to follow up on Administrator certificate and met with staff Rodrigo Gallardo. Licensee Nick Aquino was not able to come to the facility, but gave authorization to staff to sign the report.

On 6/28/23 an informal meeting was conducted in the Santa Rosa Regional Office to address concerns regarding Administrator certification at this facility and the Licensee's other facility, AA Best Care 496801684 in which Licensee Nick Aquino is the identified Administrator. During annual inspection on 7/23/24, LPA issued a citation to the facility due to not having supporting evidence that submitted required documentation received by the Department's certification unit and Licensee agreed to re-submit it timely. On 7/25/24, the facility submitted certified mail tracking number dated 7/25/24 with Sacramento department's address on it to CCL to clear the citation. However, On 12/5/24, LPA have followed up with the Department's certification unit to verify that documentation mailed was received, but they stated that they had staff trying to work with them to resolve their incomplete application for almost an entire year. After multiple notices the certification unit withdrew their application due to failure to comply with Administrator Certification renewal requirements and lack of communication to remediate their application in a timely manner for both facilities.

During today's visit, LPA have a discussion with Licensee via phone regarding this issue and was told that it has been hard to appoint a certified administrator to fill out the administrator position. Per Nick, the hours needed to be completed to have their administrator certificate had been completed and they are in the process to submit required documentation for further processing.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 02:06 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/06/2024 at 01:32 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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical & Dental Care: (h) The following requirements shall apply...(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Staff removed R1's medication and locked during the visit. Licensee to submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance by POC due date 12/7/24 to CCL to clear the citation.
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Based on LPA's/staff observation and interviews conducted with staff, Licensee did not ensure medications to be kept locked and inaccessible to residents. This is an immediate health & safety risk to residents.
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Type B
12/16/2024
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
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Licensee will appoint a certified administrator for this facility and will submit required documentation to perform this change to the Department by POC due date 12/16/24. Licensee have been informed that if they don't comply with regulations civil penalties will be warrant until this issue gets resolved.
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Based on LPA's/Licensee observation, interviews and record review, the licensee did not comply with the section cited above in that Nick Aquino does not have a certified administrator from CCL, which poses a immediate health, safety or personal rights risk to persons in care.
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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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000
VISIT DATE: 12/06/2024
NARRATIVE
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Continued from LIC809...

However, Licensee agreed to appoint a certified administrator who will spend at least 20 hours in each facility. LPAs will be issuing a citation and Licensee have been informed that if they don't comply with regulations civil penalties will be warrant until this issue gets resolved.

Upon arrival, LPAs observed two caregivers were cleaning the facility and there was an unattended Timolol Maleate 0.5% eye drop medication sitting on a table located in the common area where a resident was sitting watching tv. LPAs inquired with staff and were told that they just assisted another resident with medication, but did not put the medication in the locked medication cart.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee via phone and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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