170106658-3-1-2022-21-AS-SHAN-CC4VKP-20220301153040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 170106658
Report Date: 03/01/2022
Date Signed: 03/01/2022 03:30:50 PM

Document Has Been Signed on 03/01/2022 03:30 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:	EDELWEISS GUEST HOME		FACILITY NUMBER:	170106658
ADMINISTRATOR:	MAHLMAN, LINDA		FACILITY TYPE:	740
ADDRESS:	955 POOL STREET		TELEPHONE:	(707) 263-4340
CITY:	LAKEPORT	STATE: CA	ZIP CODE:	95453
CAPACITY:	15	CENSUS: 8	DATE:	03/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee Linda Mahlman		TIME COMPLETED:	03:30 PM

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On 3/1/2022 at 12:30 PM License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1-year infection control inspection visit of the facility. LPA was welcomed by staff Marie Rivera. Administrator Linda Mahlman. There is a total of 8 residents at facility,there are no residents on hospice or have dementia at this time.

At approximately 12:45 PM, 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 visible area. 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 secure room off of the kitchen. Hot water temperature measured between 124.7 degrees F and 125.2 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 4 resident’s bathroom faucets. Fire extinguishers inspected were charged on 5/24/2021. Smoke detectors were in working order. Facility has fire sprinklers throughout. Fire suppression system was last inspected June, 2020. Carbon Monoxide detectors were checked and in working order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in locked cabinets in room area behind kitchen/office.

Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 1/27/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in dinning room cabinet, dresser in front hallway and in pantry. Facility has a 30-day supply of medication for residents. Staff had all PPE training required as well have been N95 Fit Tested. All staff have been fully vaccinated and received their COVID booster shots and all staff work exclusively at this facility.

Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

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: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
	VISIT DATE: 03/01/2022

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In addition, facility has designated areas for visitors in bedrooms (they are all individual) and other areas which are being allowed for visits. Residents also have available zoom, facetime, and telephone calls when contacting with family members and others and assistance if needed. Facility has not conducted a disaster drill in the last 2 years.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information other than add Licensee’s cell number. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was informed by Licensee no staff have current CPR & or 1^st Aid certification.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/15/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/01/2022 03:30 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: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews conducted, the licensee did not comply with the section cited above per regulation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2022
	Plan of Correction
1 2 3 4	Licensee to submit written plan, outlining how facility will conduct required drills per regulation. Licensee will also conduct a drill and submit written evidence of completed drill to CCL by POC date of 03/22/2022

Type B

Section Cited

HSC

1569.618(c)(3)

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses an immediate health, safety risk to residents in care.
	POC Due Date: 03/22/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that at least one staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that staff have been CPR trained per regulation and that facility will maintain a staff on duty who has CPR training at all times by POC due date 03/22/2022.

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/01/2022 03:30 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: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 2 of 4 resident's bathrooms which poses an immediate Health, Safety risk for esidents in care. LPA toured the facility with Licensee Ermelinda Mahlman on 3/1/2022 at 12:45 PM & observed that hot water temperature ranged between 124.7.degrees F and 125.2 degrees F.
	POC Due Date: 03/02/2022
	Plan of Correction
1 2 3 4	Licensee to ensure water temperature is maintained within regulation - 105 TO 120 F. Licensee to submit a LIC 9098 seff certification that hot water temperature is within regulation by POC date of 3/2/2022 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 3/8/2022.

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/01/2022 03:30 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: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411(c)(1) PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on interview with Licensee, the facility did not ensure that all staff have current 1st aid. LPA learned that 5 of 5 staff do not not have proof of current first aid certification which poses a potential health & safety risk to residents in care.
	POC Due Date: 03/22/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1 to CCL by POC date of 3/22/2022.

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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