170106658-1-9-2024-21-AS-SHAN-CZBSE9-20240109124822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 170106658
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:48:33 PM

Document Has Been Signed on 01/09/2024 12:48 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: 6	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Linda Mahlman, LIcensee/Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE

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On 1/9/2024 at 9:00 AM License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual visit of the facility. LPA was welcomed by Administrator Linda Mahlman. There is a total of 6 residents at facility, two with dementia, and no residents on hospice.

At approximately 9:10 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 observed by LPA & Licensee unlocked on 1/9/2024 at 9:15am (see LIC809-D). Hot water temperature measured between 105.6 degrees F and 117.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 3 resident’s bathroom faucets. Facility has 8 fire extinguishers throughout, all charged on 5/4/2023. Smoke detectors and Carbon Monoxide detectors were checked and in working order. Facility has fire sprinklers throughout. Fire suppression system was last inspected January 3, 2024. 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.

At approximately 10:00 AM, LPA reviewed 6 of 6 resident records and found 6 of 6 residents records contained current appraisals and signed admission agreements. Although 1 of 6 residents records did not contain current physician reports (LIC602) (see LIC809-D). Medication records are thorough and contained physician's orders for each resident.

At approximately 11:00 AM, LPA reviewed 3 of 3 staff records. 3 of 3 records contained documentation of completed training as required. Evidence of current CPR training provided, although 3 of 3 staff could not provide current 1^st Aid Certification (see LIC 809-D). LPA interviewed 2 staff during this inspection.

Continue on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 01/09/2024 12:48 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 LPA's observation of record review, the licensee did not comply with the section cited above in 1 out of 2 residents with a dementia diagnosis did not have an annual Medical Assessment (LIC602) last was 2020. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	LIcensee to assist in getting resident (R1) a doctors appointment to update Medical assessment and submit updated LIC 602 to CCL by 1/26/2024 to clear citation. On same submission submit plan on how to prevent reocurance of violation of regulation.

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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: 01/19/2024
	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 1/19/2024.

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: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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: 01/09/2024

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At approximately 11:45 PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a commercial generator to supply power during an outage for entire facility for over a week. 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. Facility has conducted and documented quarterly disaster drills with the last being 10/12/2023.

LPA reviewed Licensing Information System (LIS) with Lisignee who stated that is correct and updated at this time; no need to change any of the information. Administrator Certificate is for Ermelinda Mahlman #6022851740 expires 12/6/2024.

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 facility to submit the following documents to CCL by 1/25/2024:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Certificate 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: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2024 12:48 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411(c )(1) Personnel Requirements – General 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. Staff providing care shall receive appropriate training in first aid 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	Based on LPA's observation and record review, three out of three care staff LPA reviewed records lacked required first aid certification, the licensee did not comply with the section cited above in 3 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 1/19/2024

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: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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