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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:59:00 PM

Document Has Been Signed on 12/12/2023 04:59 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:CARRIAGE HOUSEFACILITY NUMBER:
496803595
ADMINISTRATOR:BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5695 CARRIAGE LANETELEPHONE:
(707) 303-7159
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
12/12/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Melanie & RusselTaningco-CaregiversTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst(LPA) Alviso conducted Required-1 Year inspection and met with live-in caregivers Melanie and Russel Taningco. Administrator Josephine Blancaflor was contacted by staff to notify them of LPA's arrival to the facility.

There are six (6) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval (room #1 only).
Facility has an approved dementia plan of operation. Hospice waiver approved for one (1) resident. Facility has a required infection control plan. Facility has a required emergency and disaster plan.

The LPA reviewed six (6) resident files. All files were complete.
The LPA reviewed three (3) staff files. All staff have criminal record clearance as required. All staff have training.
There was a sufficient supply of food, hygiene products, cleaners, and paper products. All auditory alarms were working as required.

Based on LPA's review of facility records, and staff interviews, there have been no emergency drills conducted as required, quarterly drills; One of the quarterly drills must be a facility evacuation drill. The last drill per record review was in 2019. This deficiency will be cited. H&S Code 1569.695(c)- A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and Health and Safety Code.
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided to staff Melanie Taningco for the Administrator.
Exit interview conducted with staff Melanie Taningco.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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 12/12/2023 04:59 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/12/2023 at 04:39 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: CARRIAGE HOUSE
FACILITY NUMBER: 496803595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of facility records, and staff interviews, there have been no emergency drills conducted as required, quarterly drills; One of the quarterly drills must be a facility evacuation drill. The last drill per record review was in 2019, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licensee/Administrator to ensure the facility is conducting quarterly emergency drills as required. Submit plan of compliance with the H&S 1569.695(c). Licensee to conduct a facility emergency drill with staff, on every shift, and submit a copy of the drill along with facility compliance plan. POC due 12/29/23.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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