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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800937
Report Date: 03/07/2022
Date Signed: 03/07/2022 12:01:35 PM

Document Has Been Signed on 03/07/2022 12:01 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:SARAH'S SENIOR RESIDENTIAL CAREFACILITY NUMBER:
496800937
ADMINISTRATOR:ARAYA, SARAHFACILITY TYPE:
740
ADDRESS:1601 CLOVER DRIVETELEPHONE:
(707) 542-4082
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 4DATE:
03/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Saray Araya (Administrator)TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Administrator, Sarah Araya. LPA conducted risk assessment call with Administrator. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

During today's visit LPA is following up on an incident report received at CCL on 2/22/22 involving resident (R1) and staff (S1). On 2/22/22 Administrator received a call from S1 informing her that R1 had been given another resident's medication by error and R1 had fallen asleep during breakfast. Administrator called 911 immediately and R1 was transported to Kaiser Emergency Department. Administrator also notified responsible parties including North Bay Regional Center. Facility terminated S1 and staff is not longer working at the facility. Also, all staff received medication training on 2/22/22 and implemented a new process to designate a medication desk underneath medication cabinet were residents will come one at a time to receive their medications to avoid future medication errors. During this visit LPA reviewed R1's discharge paperwork and there are no medication changes for R1. ***Immediate civil penalty in the amount of $500 has been issued due to the medication error.

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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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 03/07/2022 12:01 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/07/2022 at 11:23 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: SARAH'S SENIOR RESIDENTIAL CARE
FACILITY NUMBER: 496800937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2022
Section Cited
CCR
87465(a)(5)

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87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. Facility staff failed to give residents' their medications as ordered/prescribed by the Physician. This requirement has not been met as evidence by:


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Administrator submitted proof of medication management training conducted with all staff & will write a plan to ensure resident medications are properly managed. Administrator will submit the updated plan to CCL by POC due date. ***Immediate civil penalty in the amount of $500 has been issued.
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Based on records review and interviews R1 received the wrong medication and was provided with another resident's medication in error by staff (S1). R1 was sent to the Emergency Room after taking the wrong medication which poses an immediate risk to the health and safety of residents 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: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022


LIC809 (FAS) - (06/04)
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