Routine inspection·December 4, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Rosa Soto. At approximately 9:30am LPA 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. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. 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 113.5 and degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 3/26/24. Smoke/Carbon Monoxide detectors located throughout the facility are hard wired and last serviced by Santa Rosa Fire Equipment Inc on 9/18/24. Facility’s has not documented quarterly disaster drills, LPA discussed making sure they document the disaster drills and conduct them quarterly. Facility has sliding vertical locks on the doors and upstairs fire exit door had both a chain lock and vertical sliding lock. Facility immediately removed all vertical locks and chain lock from upstairs. Facility has a backup generator for use during a power outage. At approximately 10:30am LPA conducted review of 5 staff records. All required documentation present. LPA discussed training materials. Currently used training materials are videos from Community Care Options dated 2011. LPA discussed either updating training materials to something current and pertinent or using an approved vendor to conduct staff training. Facility will submit pictures of updated materials to CCL if an approved vendor is not chosen. Continued on 809C... Continued from 809... At approximately 11:30am LPA conducted a review of 5 resident records. All required documentation present. At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Centrally Stored Medication log not completed for R1 ( deficiency cited, see 809D ). LPA discussed pre-pouring medications. Admin advised that they pour in the morning for morning meds and pour in the afternoon for evening meds. Admin advised they never pre-pour medications the previous evening for the next day. Rosa Soto Administrator Certificate 6006777740 expires 8/29/25. 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 LIC308- Designation of Responsibility 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 Licensee. 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 .