125000592-9-13-2023-21-AS-CARD-CVMTH6-20230913144413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 125000592
Report Date: 09/13/2023
Date Signed: 09/13/2023 02:44:22 PM

Document Has Been Signed on 09/13/2023 02:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	RENAISSANCE AT TIMBER RIDGE		FACILITY NUMBER:	125000592
ADMINISTRATOR:	FARNUM, LARONA		FACILITY TYPE:	740
ADDRESS:	2780 TIMBER RIDGE LANE		TELEPHONE:	(707) 443-3000
CITY:	EUREKA	STATE: CA	ZIP CODE:	95503
CAPACITY:	22	CENSUS: 21	DATE:	09/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Larona Farnum		TIME COMPLETED:	03:00 PM

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	At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Licensee Larona Farnum. At approximately 8:45AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 10:45AM, LPA reviewed 5 of 21 resident records. LPA found 5 residents did not have current care plans. 5 of 5 records contained current and signed admission agreements and physician's orders. Medication records are thorough and contained physician's orders for each resident. At approximately 12:00PM, LPA reviewed 5 staff records. 5 of 5 records did not contain documentation of completed training as required. Evidence of current first aid and CPR training were current. LPA interviewed 2 staff during this inspection. Continued on LIC 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RENAISSANCE AT TIMBER RIDGE	FACILITY NUMBER: 125000592
	VISIT DATE: 09/13/2023

NARRATIVE

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At approximately 1:30PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency.

During this annual inspection, LPA followed up on an incident report submitted by the facility on 09/01/2023. Resident was exit seeking and was able to exit through a window and leave the building. Resident was found a short time later approximately half a block away.

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
Evidence of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Larona Farnum and Appeal rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2023 02:44 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RENAISSANCE AT TIMBER RIDGE	FACILITY NUMBER: 125000592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. 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 5 of 5 resident files. Residents were not reappraised, leading to 1 resident leaving the building without staff knowledge. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/14/2023
	Plan of Correction
1 2 3 4	Licensee to submit a written plan outlining how facility will ensure all reappraisals are updated when needed or at least annually. Self Certification that all appraisals are updated to be submitted to CCL by POC date of 10/13/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2023 02:44 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RENAISSANCE AT TIMBER RIDGE	FACILITY NUMBER: 125000592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(1)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. 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 5 of 5 staff records. Staff did not have evidence of completed training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit written plan/procedure outlining how facility will ensure staff receive initial and ongoing training per regulation. Completed training procedure to be submitted to CCL by POC date of 10/13/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC809 (FAS) - (06/04)

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