175001941-12-4-2023-21-AS-SHAN-CY7SYQ-20231204131754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 175001941
Report Date: 12/04/2023
Date Signed: 12/04/2023 01:18:07 PM

Document Has Been Signed on 12/04/2023 01:18 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:	A NICE CARE HOME		FACILITY NUMBER:	175001941
ADMINISTRATOR:	GAMBONINI, CHERYL		FACILITY TYPE:	740
ADDRESS:	6784 CRUMP AVENUE		TELEPHONE:	(707) 274-9938
CITY:	NICE	STATE: CA	ZIP CODE:	95464
CAPACITY:	6	CENSUS: 5	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Cheryl Gambonini, Licensee/Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE

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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. inspection of the facility. LPA was welcomed by Licensee – Cheryl Gambonini. There are 5 residents at facility, currently 1 on hospice 2 with diagnosis of dementia.

LPA conducted tour of facility on 12/4/2023 at 9:00 AM with Licensee/Administrator and observed; facility was found to be clean and in good repair; all walkways and exits were free from obstruction. Exits were equipped with auditory devices. Fire Extinguisher was found to be last charged on 12/14/2022 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Facility has fire sprinklers throughout, last inspection conducted will be submitted. There was enough lighting in all common areas, resident rooms, and hallways. Hot water temperature measured between 111 degrees F and 114.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 12/4/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the kitchen and locked closet in hallway. Kitchen drawer containing sharps was inaccessible to residents in care.

There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers, although staff informed some residents flush paper towels and clog toilets. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings per Title 22 Regulations.

Continue 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: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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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Document Has Been Signed on 12/04/2023 01:18 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: A NICE CARE HOME	FACILITY NUMBER: 175001941
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 record review and interview the licensee did not have at least one staff member who has CPR training on duty at all times. Facility has 4 out of 4 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.
	POC Due Date: 12/15/2023
	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 at least one staff has been certified for CPR per regulation and that facility will maintain a staff on duty who has CPR training at all times. Self certification and copy of CPR certificate to be submitted by POC date of 12/15/2023

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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: A NICE CARE HOME	FACILITY NUMBER: 175001941
	VISIT DATE: 12/04/2023

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A review of five resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:00 AM and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A).

LPA reviewed a sample of staff records at 11:45 PM and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2023 are on file. LPA was presented with proof of 1^st Aid certification for staff files reviewed; although no staff had current CPR certification (see LIC 809-D).

Medication is centrally stored and secure in locked cart in dining room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 12/4/2023 at 12:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. Cheryl Gambonini Administrator Certificate # 6007021740 expired but LPA was provided proof of training's and documents with payment sent, recertification received on 1/10/2023, still pending. Disaster Drills are conducted quarterly with the last one being conducted on 5/17/2023. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternate meeting locations.

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 the following documents and submit to CCL by 1/8/2023:

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: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

Page: 6 of 7

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: A NICE CARE HOME	FACILITY NUMBER: 175001941
	VISIT DATE: 12/04/2023

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 26 27 28 29 30 31 32	LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Fire Sprinkler Inspection Copy of Control of Property/Deed Copy of Administrator Certificate 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: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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