Routine inspection·December 4, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Martha Marimbi. At approximately 1:30pm LPA and Admin 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 are stored in locked in outside laundry room. 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 118.9 degrees F in the bath off the kitchen, 112.4 degrees F in the cottage and 114.3 degrees F in room #2 which are all within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 2/22/24. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced annually by Santa Rosa Fire Equipment Inc, last serviced on 9/2024. Facility’s last quarterly disaster drills were conducted on 9/26/24. Facility has a backup generator for use during a power outage. At approximately 2:00pm LPA conducted a review of 3 resident records. Resident (R1) did not have an appraisal on file ( deficiency cited, see 809D ). Continued on 809C... Continued from 809... At approximately 2:30pm LPA conducted review of 4 staff records. LPA reviewed training materials with Admin. Admin advised that the training materials used are videos inherited from the licensee and are dated 2011 or earlier. LPA observed some training materials to be printed training modules issued by Advanced Healthcare Studies, LLC but did not have a date of publication. 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. Facility will submit to CCL the pictures of the chosen materials or their selected approved vendor by 12/18/24. At approximately 3:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Resident (R2) had two medications, Indapamide 2.5mg and FeroSul 325mg, not logged on the Centrally Stored Medication log ( deficiency cited, see 809D ) Martha Marimbi Administrator Certificate 7018478740 expires 3/21/25. 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 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 Admin. 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 .