210110626-5-4-2022-21-AS-CFGS-CE4UFP-20220504153303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210110626
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:34:58 PM

Document Has Been Signed on 05/04/2022 03:34 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:	CEDARS-NOVATO BOULEVARD		FACILITY NUMBER:	210110626
ADMINISTRATOR:	IAN RAMOS		FACILITY TYPE:	735
ADDRESS:	1840 NOVATO BLVD		TELEPHONE:	(415) 898-8486
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY: 5		CENSUS: 5	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ian Ramos - Administrator		TIME COMPLETED:	03:32 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	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator Ian Ramos. Rob Robinson Director Residential Services was contacted by phone. Clients were in day program. There are activities planned for clients during the day if they want to participate. LPA arrived at the facility and observed a table outside with few items for staff and visitor’s by outside entry door. During facility tour on 5/4/2022 with administrator Ian Ramos facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 03/2022 at the time of the visit. Carbon monoxide detector and sample smoke detectors test was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods 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 closet in the hallway. There was a supply of cleaners, hygiene products and paper products available for clients. Sample of client’s bedrooms were inspected and had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 99.5 degrees F and 103.4 degrees F in 3 out of 3 faucets failing out of Title 22 acceptable regulations of 105 to 120 degrees F. LPA w/ administrator let the water run to see if it would warm up, but it didn’t work. Then administrator and LPA turned off and checked again in the end of the visit. Disaster drills are being conducted monthly with records for last fire drill on 05/03/2022. Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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: CEDARS-NOVATO BOULEVARD	FACILITY NUMBER: 210110626
	VISIT DATE: 05/04/2022

NARRATIVE

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Infection Control:
Facility has submitted a COVID-19 mitigation program plan that has been approved. Posters have been placed at facility, container with hand sanitizer and other items designated for visitors and staff are at entrance. Staff before coming into work has temperature checked. Facility has some PPE supply stored in the garage area and main corporation office. There has been new staff hired and new clients since last year’s visit. Clients’ medications are stored and locked in medication cabinet in a locked office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available virtual and telephone calls when contacting with family members and others. Per staff all PPE training required is on file and staff has acquired N-95 fit testing.

Department is requesting Licensee to update the following documents and submit to CCL by 5/11/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2022 03:34 PM - It Cannot Be Edited

Created By: Carla Fernandes-Goes On 05/04/2022 at 03:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CEDARS-NOVATO BOULEVARD	FACILITY NUMBER: 210110626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 clients' faucets which poses/posed a potential health, safety or personal rights risk to persons in care. LPA during tour of facility with administrator observed that hot water temperature on clients' faucets measured between 99.5 degrees F and 103.4 degrees F in clients' faucets.
	POC Due Date: 05/18/2022
	Plan of Correction
1 2 3 4	Facility to ensure that hot water temperature measure withing Title 22 Regulations of not less than 105 degrees F and not more than 120 degrees F. Facility to adjust hot water heater and submit a 7 day hot water temperature log by 5/18/2022 in order to clear this citation.

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

LICENSING EVALUATOR NAME:

Carla Fernandes-Goes

LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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