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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803639
Report Date:
02/17/2022
Date Signed:
02/17/2022 03:33:44 PM
Document Has Been Signed on
02/17/2022 03:33 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:
PEOPLE'S CARE CHARMIAN
FACILITY NUMBER:
496803639
ADMINISTRATOR:
SEAWRIGHT, PATRICK
FACILITY TYPE:
740
ADDRESS:
5087 CHARMIAN DR
TELEPHONE:
(951) 775-7411
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95409
CAPACITY:
4
CENSUS:
3
DATE:
02/17/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
03:00 PM
MET WITH:
RN, Rene Litzenberg
TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/17/2022 to follow up on an incident received by community care licensing on 01/21/2022. LPA met with Rene Litzenberg
Incident report indicated staff had failed to administer one dose of medication to client. Client was monitored for changes of condition upon discovery. No adverse reactions were noted. Facility planned to conduct medication training for staff involved.
LPA reviewed facility policy on medication administration and medication errors/reporting which were signed by staff. LPA also reviewed medication checklist which administrator uses to verify staff are following proper procedure. Training materials reviewed by staff were signed on 01/26/2022.
No deficiencies cited during this inspection. Exit interview conducted and a copy of this report will be emailed to the administrator.
SUPERVISORS NAME
:
Kimberley Mota
LICENSING EVALUATOR NAME
:
Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/17/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/17/2022
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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