170106658-1-24-2023-21-AS-SHAN-CNDQW6-20230124113125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 170106658
Report Date: 01/24/2023
Date Signed: 01/24/2023 11:31:42 AM

Document Has Been Signed on 01/24/2023 11:31 AM - 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: 7	DATE:	01/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Linda Mahlman - Administrator		TIME COMPLETED:	11:40 AM

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On 1/24/2023 at 9:00 AM 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 Administrator Linda Mahlman. There is a total of 7 residents at facility, one with dementia, and no residents on hospice.

At approximately 9:25 AM, 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. Although sharps and toxins in kitchen were unlocked (see LIC 9120) for Technical Assistance. Hot water temperature measured between 103.6 degrees F and 109.9 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 3 resident’s bathroom faucets (see LIC 9120) for Technical Assistance. Fire extinguishers inspected were charged on 5/18/2022. Smoke detectors were in working order and Carbon Monoxide detectors were checked and in working order as well. Facility has fire sprinklers throughout. Fire suppression system was last inspected August, 2022. 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 and infection control plan. All staff and visitors check in and log. 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.

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: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
	VISIT DATE: 01/24/2023

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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 since 3/25/2022 which was with the fire department (see LIC 9120) for Technical Assistance.

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. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Ermelinda Mahlman #6022851740 Exp. 12/6/2022 (renewal completed 10/5/2022)
All staff have received COVID booster vaccinations and work exclusively at this facility

Facility given 4 Technical Assistance’

No deficiencies cited during today’s inspection

LPA Hansen is requesting Licensee to update and submit the following documents by 2/7/2023 to RPRO:

LIC 308 Designated

LIC 400 Cash Resources

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: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC809 (FAS) - (06/04)

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