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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803595
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:43:29 PM

Document Has Been Signed on 12/04/2024 01:43 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:CARRIAGE HOUSEFACILITY NUMBER:
496803595
ADMINISTRATOR/
DIRECTOR:		BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5695 CARRIAGE LANETELEPHONE:
(707) 303-7159
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
12/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Melanie Taningco-Live-in CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Alviso conducted continued annual inspection and met with live-in caregiver Melanie Taningco. LPA observed a second caregiver, Jennie, working in the facility upon arrival. Administrator Josephine Blancaflor was contacted, and arrived within the hour to meet with the LPA.

There were six (6) residents in care during the LPA's inspection. 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 a required infection control plan. Facility has a required emergency disaster plan.

LPA reviewed facility records. Emergency Disaster drill are conducted as required, quarterly drills with one being an evacuation drill. Last drills conducted with facility staff were held on 9/30 and 6/29, 2024.

LPA observed all utilities were working appropriately and available for use as required for facility operations. Fire extinguishers (2) were serviced and tagged as required. All exits were clear and unobstructed. Facility was clean and orderly. Food supply was sufficient with both perishable and non-perishable foods; LPA observed lots of fruit on the kitchen counter which is used for residents meals and snacks. Resident rooms, bathrooms, hallways, and common areas had sufficient lighting for residents in care. All disinfectants and cleaners were locked and inaccessible to residents in care. All medications were locked and inaccessible to residents in care. The facility was at a comfortable temperature. There was a sufficient supply of hygiene products, linens, cleaners/disinfectants, personal protective equipment (PPE), and paper products.

LPA reviewed six (6) resident files, including a review of resident medications/logs.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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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: CARRIAGE HOUSE
FACILITY NUMBER: 496803595
VISIT DATE: 12/04/2024
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LPA reviewed four (4) staff files, including staff required training.

LPA is requesting the following documents be updated and submitted by 1/4/2025:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate

LPA observed the following deficiencies which will be cited today:
LPA observed the backyard fire exit gate to be broken, a bit slanted down, large and heavy, and not able to open freely as needed during an emergency. LPA obtained photos. The Administrator stated they have an estimate to have the gate and it's side fencing redone and balanced as needed, so the fire exit gate works appropriately. This deficiency will be cited, 87203 Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal rights provided to the Administrator.
Exit interview conducted with Licensee/Administrator Josephine Blancaflor.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 01:43 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/04/2024 at 12:22 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the backyard fire exit gate is broken, a bit slanted down, is large and heavy, and not able to open freely as needed during an emergency. LPA obtained photos, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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The Administrator stated they have an estimate to have the gate and it's side fencing redone and balanced as needed, so the fire exit gate works appropriately. Administrator will submit plan of correction for repairing/redoing the fire exit gate so it works appropriately. Ensure all staff are aware and trained on ensuring the opening of the fire exit gate in the event of an emergency. The fire exit gate will be repaired/redone in a timely manner, which will be within a two week time frame. Follow-up by 12/18/24 with photos, and written statement on how the fire exit gate was repaired/redone and is working appropriately. POC due 12/5/24.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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