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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803337
Report Date: 02/03/2025
Date Signed: 02/03/2025 02:32:06 PM

Document Has Been Signed on 02/03/2025 02:32 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:BUCKINGHAM RESIDENTIAL CARE HOMEFACILITY NUMBER:
496803337
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:954 BUCKINGHAM DRIVETELEPHONE:
(707) 888-5259
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Angelica Martinez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required Visit. Administrator, Angelica Martinez, arrived to facility at approximately 9:20 AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for five (5) non-ambulatory residents and one (1) ambulatory resident for a total capacity of six (6) residents. Facility has an approved hospice waiver for two (2) individuals. Upon arrival, LPA was informed that there were five (5) Residents in care and three (3) staff members on-site.

At approximately 9:30 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation with the exception of one (1) staff member (S3) who had background clearance but was not yet associated with the facility. Please see the attached 809-D regarding S3 not being associated to the facility. At approximately 10:00 AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 2 story building with 6 Resident bedrooms, 3 resident bathrooms, one shower room, 2 staff rooms, 1 staff bathroom, and common spaces. LPA observed that two (2) of two (2) residents' bathrooms did not have waste receptacles with tight fitting covers. A Technical Violation (TV) was issued for the waste receptacles not being in compliance. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.
Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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Document Has Been Signed on 02/03/2025 02:32 PM - It Cannot Be Edited


Created By: Robert Frank On 02/03/2025 at 01:27 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: BUCKINGHAM RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803337

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that S1 did not have a complete LIC 501 Personnel Record. The second (2nd) page was missing. LPA further observed that S2's LIC 501 Personnel Record was not signed. The licensee did not comply with the section cited above in that two (2) Personnel records did not have required documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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Administrator will submit to Community Care Licensing (CCL) the completed LIC 501 Personnel records for S1 and S2 by POC Due Date of 2/11/2025. Administrator will self certify that she has reviewed all employee files to ensure that they are in compliance with regulations by the POC Due date of 2/11/2025.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 in that S3 was not associated with the facility in the Guardian Background Check system. S3 did have background clearance but was not associated to the facility.
POC Due Date: 02/11/2025
Plan of Correction
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Administrator will self certify that S3 will not work in the facility until S3 has been properly associated to the facility in the Guardian back ground check system. Administrator will provide CCL with the self certification by POC Due Date of 2/11/2025.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


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: BUCKINGHAM RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803337
VISIT DATE: 02/03/2025
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...Continued from 809
During walk through, LPA observed that facility currently does not have an evacuation chair on-site, but all residents currently live on the first floor. A Technical Violation (TV) was issued for the facility not having a evacuation chair on site. LPA advised Administrator to purchase an evacuation chair in the event they have a resident move into the room located on the second floor.

LPA reviewed five (5) resident files. Five (5) of five (5) resident files were found to be well organized and thorough with all required documentation. LPA reviewed four (4) staff files. During staff file review, LPA observed that two (2) staff files did not have or have an incomplete LIC501/Personnel Reports. Please see the attached 809-D regarding missing staff files. Staff files had current First Aid and CPR certification and proper training documentation. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. Facility's fire extinguishers were found to be last inspected September 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility conducts emergency drills quarterly with the last emergency drill conducted 1/15/2025.

Administrator's Certificate for Angelica Martinez (70000290740) is current with an expiration date of 04/10/2025

LPA is requesting the following documents be submitted to Community Care Licensing (CCL) by DOB: 3/3/2025
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance

Exit interview conducted. Copy of report, LIC809D (Deficiency Page) with plans of corrections, LIC9102s Technical Violations, Confidential Names (LIC811), and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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