Facility Evaluation Report

A Non-Compliance meeting was conducted today, 6/29, in the Santa Rosa Regional Office. Present in the meeting were Regional Manager Carla Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Dina Alviso, facility Administrator Susan Webster, and Regional Director Reggie San Pablo.

This Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency regarding the operation of this facility, regarding Complaint #21-AS-202303221 42833, received on 3/22. The investigation substantiated that the facility is not operating in a sanitary manner and/or in good repair; Clients are not able to use restroom toilets in a sanitary manner, and Facility is not submitting required reports/incidents. The following are concerns that have been identified during the complaint investigation:

Building & Grounds: Facility’s toilets (2) were not working appropriately/not able to be used, and clients were made to use the toilet(s) in an unsanitary manner.

Personal Rights: The facility staff started using plastic bags in the toilet(s) for clients to urinate and/or have bowel movements in, this was instituted by staff when the toilets couldn’t be used.

Reporting Requirements: Facility did not ensure that CCL was notified about incident(s), that began on 3/13, after facility restrooms both had flooding, separate incident dates, due to a septic tank issue; The septic tank issue resulted in the facility toilets (2) not being able to be used. The facility never contacted licensing to report the incident, and the facility didn’t submit the required written report until 3/22/23.