Post-licensing visit·November 2, 2023

Licensing Program Analyst (LPA) Cuadra conducted the Post Licensing inspection and met with lead staff Cassie Guerrero designated substitute on file. Licensee/Administrator was not able to come to the facility due to their residency is a distance away from the facility, which it was previously discussed with Licensee during pre-licensing visit conducted on 12/15/22. LPA have a discussion via phone with Licensee and was informed their intentions are to appoint an Administrator that will ensure to spend a reasonable amount of time in the facility, resident's care needs will be met in case of an emergency and Community Care Licensing inspections. Documents needed to appoint a new Administrator are as follow: (LIC 500) Personnel Report, LIC308 Designation of Facility Responsibility, LIC215 Applicant Information, LIC501 CCL/Personnel Record and detailed employment/education history. Facility has a Dementia Care Plan approved to care for residents with dementia care needs. No residents in hospice. Facility is a single story residence and has 5 bedrooms for residents in care. The fire clearance for six non-ambulatory residents was granted 11/1/2022 by Sonoma County Fire Department. Fire extinguisher was last serviced 12/13/2022. The facility have not conducted a fire drill for the last quarter. LPA/Staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Smoke alarms and carbon monoxide detector were tested and operational at time of inspection. Auditory alarms were functional at time of inspection. Water temperature in bathroom used by residents measured 127.6 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Required postings observed. Continued on LIC809C... Continues from LIC809... Extra hygiene products and linens were available. Cleaning supplies are stored in the locked laundry room. Facility has at least two days of perishable and one week of non-perishable foods. Facility has emergency food and water supplies. Bathrooms had required bath mats and grab bars. LPA/lead staff observed cameras located in three locations in the common areas. Per lead staff, the cameras are not working at this moment, but they have not decided if they are going to proceed to install their own cameras or not. Licensee agreed to notify CCL of any updates and is aware that if they decide to install them, the facility plan of operation and admission agreement informing family of video surveillance will need to be submitted to CCL for review. Medications and medication records were reviewed. At approximate 10am LPA initiated resident and staff records reviewed. Five out of five staff has an active First Aid/CPR Certificate and staff's annual required training hours. All residents have a current medical assessment on file. One out of five resident's (R1) care plan needs to be updated. Licensee has not completed new Admission Agreements for 4 out of 5 residents. Medications is centrally stored and locked in a cabinet located in the hallway and inaccessible to clients. Facility agrees to submit updates of the following by 11/30/23: -LIC 500 Personnel Report -LIC308 Designation of Facility Responsibility. -Copy of Liability Insurance -Control of Property. -LIC 610 Emergency Disaster Plan (If changes) -Infection Control Plan (If changes) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Lead Staff, Licensee was made aware of citations via phone and a copy of this report was given.