075601503-12-20-2023-15-AS-AGOZ-CYJU6C-20231215141808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601503
Report Date: 12/15/2023
Date Signed: 12/20/2023 01:41:43 PM

Document Has Been Signed on 12/20/2023 01:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/19/2023 09:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	*THIS IS AN AMENDED REPORT* Licensing Program Analyst (LPA) A. Gomez and arrived unannounced and conducted Annual Inspection starting at 9:15AM. During the inspection, LPAs met with Administrator, Heidi Yrreverre. LPAs toured the facility inside and out with Administrator Heidi Yrreverre including but not limited to random resident’s apartments, kitchen, dining area, common area, and courtyard. The Administrator currently holds a certificate (#6047315740) that expires on 4/30/2024. The facility’s fire clearance was approved for 36 residents, all of whom may be non-ambulatory. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in Resident 4's bathroom was measured at 119.2 degrees Fahrenheit and the hot water temprature measured in Residents 5's bathroom measured at 121.5 Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower floor pan. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. LPAs observed interconnected smoke detectors and sprinklers. Carbon monoxide was in working condition during visit. Fire extinguisher was last serviced on April 23, 2023. First aid kit was observed to be incomplete and missing book. Fire and Earthquake Drill drill was last conducted respectively on January 20, 2023 and January 23, 2023. LPAs reviewed 5 staff record files and 5 of 5 staff have criminal record clearance and are associated to the facility. 4 of 4 required staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 5 residents’ files. Report Continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
	VISIT DATE: 12/15/2023

NARRATIVE

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The following deficiencies were observed:

10:00am During resident file review LPA observed that R1's file is missing an updated appraisal of needs and services, a signed emergency medical consent form, and a signed personal rights form. R3's file is also missing an emergency medical consent form
10:30am During staff file review LPA observed that S4's file is missing a criminal record statement as well as the LIC 501 job application
11:00am During record review LPA observed that Annual training's have not been completed and logged since 2019. Administrator stated that they have not done any training's other than sexual harassment, hospice dementia, and home health but that the outside vendors took the sign in sheet.
11:30am During facility tour LPA observed laxative suppositories, and nasal spray in random residents rooms. LPA also observed unlocked prescription grade laxative in bottom right cabinet located in the residents shared dining room. Administrator removed and locked away medications during visit.
11:45 During facility tour water Temperature in R5's bathroom measured at 121.5F
12:05pm During facility tour LPA observed first aid kit to be incomplete and missing instructional book.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/31/2023

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/15/2023 02:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in R5's hot water temprature measuring at 121.5F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2023
	Plan of Correction
1 2 3 4	By POC date Administrator agrees to adjust water temprature and self certify that water temprature follows regulation guidelines and notify CCLD

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in laxative suppositories, and nasal spray in random residents rooms and unlocked prescription grade laxative in shared dining room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2023
	Plan of Correction
1 2 3 4	Administrator removed medications from residents room and locked away laxatives during visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/15/2023 02:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in S4 not having a crimnal record statement on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2023
	Plan of Correction
1 2 3 4	By POC date administrator agrees to have S4 complete a criminal record statement and submit a copy to CCLD

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in R1's file is missing an updated appraisal of needs and services, a signed emergency medical consent form, and a signed personal rights form. And R3's file missing an emergency medical consent form which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2023
	Plan of Correction
1 2 3 4	By POC date administrator agrees to review all residents files and insure that they are complete and submit a self certification to CCLD

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/15/2023 02:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the first aid kit missing the manual which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2023
	Plan of Correction
1 2 3 4	By POC date administrator agrees to obtain a complete first aid kit that meets regulation guidelines and submit photographic proof to CCLD

Type B

Section Cited

CCR

87411(C)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in not having a record of required annual trainings which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2023
	Plan of Correction
1 2 3 4	By POC date administrator agrees to administer required training to all staff and submit certifications to CCLD

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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