496804138-9-28-2023-21-AS-SHAN-CW4SEQ-20230928134907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804138
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:49:16 PM

Document Has Been Signed on 09/28/2023 01:49 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:	TAKING THE JOURNEY NORTH		FACILITY NUMBER:	496804138
ADMINISTRATOR:	ERIKSEN, KELLY		FACILITY TYPE:	740
ADDRESS:	2125 MCSWEEN LN		TELEPHONE:	(707) 338-8812
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY: 6		CENSUS: 6	DATE:	09/28/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kelly Eriksen, Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection and was welcomed by staff Nancy Cuevas. Staff contacted Administrator Kelly Eriksen who arrived during inspection. There are 6 residents with 2 residents currently on Hospice. Facility tour/inspection began at 8:40 AM: LPA toured the facility on 9/28/2023; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 12/07/2022. Smoke detectors and Carbon monoxide detectors were tested and found to be operational. Hot water temperature measured between 112.4 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathroom faucets. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents any time of the day. Toxins are stored in locked laundry room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms at the facility were supplied with paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. File Review began at 10:45 AM: A sample review of six residents & five staff records as well as two resident’s medications was conducted. LPA learned that 6 out of 6 residents have updated reappraisal/needs & care plan as well as medical assessments. Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAKING THE JOURNEY NORTH	FACILITY NUMBER: 496804138
	VISIT DATE: 09/28/2023

NARRATIVE

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As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions; although new staff from sister facility (with background clearance & exemption), facility has had delay with guardian response (contacts provided). In addition, Direct care staff have received the additional training requirements; LPA was also provided required proof of CPR & 1^st Aid certification.

Medication Audit began at 1:20 PM:
Medications were centrally stored in locked front hallway closet/ medication room. LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills are conducted quarterly and in different shifts with the last one being conducted on 9/15/2023. In addition, Kelly Eriksen, Administrator Certificate # 6027539740 expires 11/4/2023.

LPA found residents to be clean and comfortable. Rooms for residents were clean and well-organized and furnished as per Title 22 guidelines.

The back porch of the house is shaded and provides a safe and secure area for residents to spend time outside.

No deficiencies were found at the time of inspection. No citations issued.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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