170106658-3-14-2025-21-AS-ADEZ-DERUSM-20250314155034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 170106658
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:50:58 PM

Document Has Been Signed on 03/14/2025 03:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	EDELWEISS GUEST HOME		FACILITY NUMBER:	170106658
ADMINISTRATOR/ DIRECTOR:	MAHLMAN, LINDA		FACILITY TYPE:	740
ADDRESS:	955 POOL STREET		TELEPHONE:	(707) 263-4340
CITY:	LAKEPORT	STATE: CA	ZIP CODE:	95453
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	LIcensee/Administrator, Ermelinda Mahlman		TIME VISIT/ INSPECTION COMPLETED:	03:55 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 09:45AM, Licensing Program Analyst (LPA) Ali Deniz made an unannounced annual inspection of this licensed senior care facility. LPA met with facility Licensee/Administrator, Ermelinda Mahlman. There is a total of six residents at facility, two with dementia, and 1 resident on hospice. Facility is a 1 story building with 9 Resident bedrooms, 1 staff bedroom, 4 bathrooms, and common spaces. At approximately 10:00AM, 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 except the Complaint Poster PUB 475 was not posted in the facility (Technical Advice given). 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. Staff were in the process of cleaning up after breakfast at the time of this inspection. During walk-though LPA/Administrator observed knifes were unlocked and administrator stated that they only clock the knife drawer and cleaning supply cabinets during the nighttime. Toxins are stored in a secure room of the kitchen. Although sharps and toxins in kitchen cabinets were unlocked (See LIC809-D page). Water temperature measured within regulation between 105- and 120- degrees F at faucets accessible to residents. Fire extinguishers inspected were charged and last inspection on 06/14/2024. Smoke detectors are hardwired into the fire system. Facility has fire sprinklers throughout. Fire suppression system was last inspected January 2024. 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 12:10PM, LPA reviewed 5 of 6 resident records and found 1 out of 5 resident R1 did not have current physician's reports or care plans. R1’s last medical assessment has done in Feb 2024 (Technical Advice given). Continued on LIC809-C...

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Ali Deniz	TELEPHONE: (707) 588-5087
	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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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Document Has Been Signed on 03/14/2025 03:50 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above while observing no staff in kitchen with knife drawer in kitchen unlocked along with cleaning suplies under kithen sink unlocked, which poses/posed a potential health, safety or personal rights risk to persons in care. LIcensee locked both cabinets immedicately
	POC Due Date: 04/11/2025
	Plan of Correction
1 2 3 4	Licensee to submit an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Training to be submitted by POC due date of 04/11/2025.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Administrator observation, interview, andrecord review, the licensee did not comply with the section cited above in 3 out of 4 staff did not complete the required initial 20 hours training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2025
	Plan of Correction
1 2 3 4	Licensee agrees to ensure 3 out of 7 staff, S2, S3 & S4, complete the initial training requirements by POC date 04/11/2025. Licensee to submit proof of completion to CCL.

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

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Ali Deniz	TELEPHONE: (707) 588-5087
	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: EDELWEISS GUEST HOME	FACILITY NUMBER: 170106658
	VISIT DATE: 03/14/2025

NARRATIVE

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Continued from LIC809...

At approximately 1:05PM, LPA reviewed 4 of 7 staff records. Based on file review, 3 out of 4 staff did not complete the required 20 hrs initial every year training (See LIC809-D page).

At approximately 1:30AM, LPA reviewed the facility emergency disaster plan with Administrator. Licensee/Administrator was not able to find documentation or proof about when the facility conducted their last disaster drill (Technical Violation given). 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 the required evacuation stair chairs in place. Facility has supplies enough to operate for more than 72 hours in an emergency. LPA was presented with proof of current CPR & 1^st Aid certification for 6 out of 7 staff. Later Administrator was able to provide proof of first aid certificate for S1. Administrator Certificate is for Ermelinda Mahlman #6022851740 expired 12/6/2024. However, administrator was able show the proof of renewal application records that she submitted on Oct 17^th, 2024.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Updated Certificate of Liability Insurance
Current Administrator Certificate

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.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Ali Deniz	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

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