210104607-2-22-2024-21-AS-CFES-D2PTQJ-20240222135602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210104607
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:56:12 PM

Document Has Been Signed on 02/22/2024 01:56 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:	DANIEL REST HOME		FACILITY NUMBER:	210104607
ADMINISTRATOR:	DANIEL, SILVANA		FACILITY TYPE:	740
ADDRESS:	28 ROOSEVELT AVENUE		TELEPHONE:	(415) 479-5522
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 4	DATE:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Licensee/Administrator, Silvana Daniel		TIME COMPLETED:	02:10 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 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Silvana Daniel. Administrator, Steven Daniel, arrived to facility at approximately 11:00AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 4 Residents in care and 1 staff member on-site. At approximately 10:00AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:15AM, LPA conducted a walk-though of the facility with Licensee/Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Resident bedrooms, 1 staff bedroom, 4 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPA reviewed staff files, resident files and resident medications. Files were all found to be well organized and thorough. Staff files had current First Aid and CPR certification. During Resident File Review, LPA observed that 2 residents did not have updated Physician Reports or Service Plans (This deficiency has been cited, see LIC809D, Regulation 87458(b)(1)). Medication was centrally stored and secure. During Medication Review, LPA observed that the facility has been pre-pouring medication for one resident. LPA notified facility that pre-pouring medications is against regulation (See Technical Violation, LIC9102, Regulation 87465(h)(5)). Licensee's Administrator's Certificate (6003231740) is current with an expiration date of 03/21/2025. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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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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: DANIEL REST HOME	FACILITY NUMBER: 210104607
	VISIT DATE: 02/22/2024

NARRATIVE

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Continued from LIC809

Facility's fire extinguisher was last inspected November 2023. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted December 2023.

LPA is requesting the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 03/22/2024.

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 (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2024 01:56 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: DANIEL REST HOME	FACILITY NUMBER: 210104607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the Licensee did not comply with the section cited above. LPA observed that 2 of 4 residents did not have an updated Physician's Report or Service Plan. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 04/01/2024
	Plan of Correction
1 2 3 4	Licensee to schedule appointments for both residents to update their Physician's Reports (LIC602). Licensee to provide scheduled dates to CCL by POC date of 04/01/2024. Licensee to also update Needs & Service Plans (LIC625) for both residents. Updated documents to be submitted to CCL by POC date 04/01/2024.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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