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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803639
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:21:49 PM

Document Has Been Signed on 03/12/2025 03:21 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:PEOPLE'S CARE CHARMIANFACILITY NUMBER:
496803639
ADMINISTRATOR/
DIRECTOR:		SEAWRIGHT, PATRICKFACILITY TYPE:
740
ADDRESS:5087 CHARMIAN DRTELEPHONE:
(707) 537-9795
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:29 PM
MET WITH:Patrick Seawright, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
03:36 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility administrator, Patrick Seawright. Administrator could not be present for entire LPA visit. LPA conducted exit interview with and gave appeal rights and copy of report to caregiver.

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On 9/17/24 CCL received an incident report from the facility regarding a medication error. Reports states that on 9/17/24, due to staff error, resident (R1) did not receive their dose of Amuity Ellipta 200mcg. R1 did not receive the medication due it being empty, a refill was not ordered in time. Reports indicates that R1 was monitored throughout the day for any adverse effects. No signs or symptoms of adverse effects observed. Per Admin, facility put in place ordering procedures to mitigate errors in refilling of medications. As of today, 3/12/25 CCL has not received any further incident reports for medication errors from the facility.

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

On 1/13/25 CCL received a SOC341 from the facility self-reporting a case of abuse toward a resident by a staff member. Facility Admin, Patrick Seawright submitted the SOC341 report. Report indicates that on 1/6/25 staff (S1) observed staff (S2) push resident’s (R2) wheelchair on to R2’s knees in an attempt to get them to get into their wheelchair. On 1/6/25 S1 reported this incident to a new hire orientation trainer. The new hire orientation trainer sent an email to People’s Care QA auditor. On 1/8/25 S1 then reported the incident to facility Admin. Facility Admin then immediately went over to R2 to check the status of their legs

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PEOPLE'S CARE CHARMIAN
FACILITY NUMBER: 496803639
VISIT DATE: 03/12/2025
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and observed no marks or bruising. On 1/12/25 facility Admin contacted S2 and placed them on Administrative leave. As of today, 3/12/25 S2 is back on active duty at the facility. Starting on 1/8/25 People’s Care Quality Assurance auditor (QA) began an investigation into the incident. Investigation lasted approximately one week and took another 2 weeks to report their findings. Admin advised LPA they did not receive any written statements from the staff. LPA asked Admin for the findings of the investigation. Admin advised they can produce the findings for CCL by 3/31/25 as they must ask the investigator for a copy of the findings. Per Admin, due to inconsistent details of the incident being reported to the QA investigator over the course of the investigation, S2 has returned work. Facility Admin reports R2 has not had any adverse behaviors observed resulting from the incident. No deficiencies cited for this SOC341 incident.

Exit interview conducted with caregiver and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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Document Has Been Signed on 03/12/2025 03:21 PM - It Cannot Be Edited


Created By: Christi Coppo On 03/12/2025 at 02:48 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: PEOPLE'S CARE CHARMIAN
FACILITY NUMBER: 496803639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement not met by licensee as evidenced by:
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Facility put in place ordering procedures to mitigate errors in refilling of medications. Facility to submit plan to CCL by plan of correction due date.
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Based on facility's submitted incident report reporting medication error, which poses an immediate health, safety or personal rights risk to persons 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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


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