Routine inspection·August 20, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator/licensee Kathleen Albano arrived later. Administrator certificate #7017523740 expires 6/7/26. Facility roster and contact information was reviewed. At approximately 10:00am LPA and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Cleaning supplies and sharp knives located in locked closet. During tour of facility, licensee and LPA observed butcher knife left unattended on kitchen island with residents present less than 2 feet away at dining table ( deficiency cited, see 809D ). During tour LPA observed ring camera video surveillance in common areas of facility as well as outside in backyard and at front door. Licensee confirmed that cameras have audio. LPA advised cameras cannot have audio as that is a personal rights violation. LPA advised that video surveillance can be present in common areas as long as the surveillance has been disclosed to residents and/or their responsible party, however the surveillance cannot include audio ( deficiency cited, see 809D ) All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 94.5 in bathroom between rooms #4 and #5 and 102.9 degrees F in bedroom #3 which is not within the allowable range of Continued on 809C... Continued from 809... 105 to 120 degrees F. But water temperatures measured at 106.6 degrees F in bathroom by room #2, and 111.7 degrees F in the kitchen which is within the allowable range of 105 to 120 degrees F. Licensee advised due to facility having 2 water heaters water has to be turned on in the laundry room in order to get hot in those rooms measuring out of regulation. LPA advised water must be hot within a reasonable amount of time, at least within 2-3 minutes of hot water being turned on. LPA discussed with licensee that a resident is not going to know or even have access to the laundry room in order to turn the water on so that they can get hot water to come out of faucet ( deficiency cited, see 809D ). Per licensee, facility has a plan to complete an expansion, but construction has not started as they have not received building permit. Licensee and drafter of blueprints went to the city of Santa Rosa's Building Permit building and showed the preliminary sketches, but that is as far as they have gotten in the process. LPA advised that LPA has concerns of potential disruption to residents in care, due to noise that this project could cause. LPA requested written plan to be submitted to CCL prior to start of the expected construction along with copy of building permit from the City of Santa Rosa. The written plan should address how the facility will ensure the health and safety of residents in care while the construction occurs, as well as materials and equipment handling to ensure they are inaccessible to residents in care. Staff will be required to continuously remind and check all residents to make sure that they are not going to the construction site and notify their responsible parties. Facility would like capacity increase from 6 to 9 residents after expansion complete. LPA advised once fire clearance is granted LPA will return to facility to complete inspection for capacity change. Fire extinguishers were last inspected 9/30/24. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 8/15/25. Facility has a backup generator for use during a power outage. At approximately 12:00pm LPA conducted review of five [5] staff records. All required documentation present. However, LPA and licensee discussed training materials. LPA and Admin discussed number of hours reported in one day for training. Licensee clarified that she does not complete the training all in one Continued on 809C(2)... Continued form 809C... day, but spreads it out over the entire year. LPA and licensee discussed using updated materials, published within the decade, so as to provide the most current information regarding dementia care. LPA will send licensee link of approved training vendors and licensee will determine if she will continue conducting her own training or instead use an approved vendor. At approximately 1:00pm LPA conducted a review of five [5] resident records. All required documentation present. 1/2 rail orders all on file.. At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA and licensee discussed the maintenance and requirements of a PRN MAR and that it must include the date and time given, the dosage, and the outcome or resident response. LPA discussed with licensee important components of maintaining the Centrally Stored Medication log (CSML). She must maintain current physician's orders and those orders must match what is written on the CSML and the information on the prescription bottle must also match what is recorded on the CSML. LPA and licensee did spot check of Quetiapine for R1. Per prescription and CSML, quantity of pills was 90. Date started was 7/20/25. R1 takes one pill daily at bedtime. So, total remaining in bottle should have been 59 pills. However, LPA and licensee got count of 37 pills ( d eficiency cited, see 809D ) . Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance 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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .