210111734-9-3-2021-21-AS-CFGS-C6HKWK-20210903081603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210111734
Report Date: 09/02/2021
Date Signed: 09/03/2021 08:16:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	WILD FLOWERS RCFE		FACILITY NUMBER:	210111734
ADMINISTRATOR:	ALLEN, C. ELIZABETH		FACILITY TYPE:	740
ADDRESS:	256 SUNSET PARKWAY		TELEPHONE:	(415) 264-7399
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY:	6	CENSUS: 6	DATE:	09/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Gladys Flores - Staff		TIME COMPLETED:	03:45 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 staff Gladys Flores. Facility has 6 residents with 1 on hospice present. Facility offers activities of music, trivia, jeopardy, and other activities. During facility tour on 9/2/2021 with staff Gladys Flores facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was last charged on 8/2021. Smoke Detectors & Carbon monoxide detectors were found to be operational during the 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. Dangerous items were stored inaccessible to clients in locked cabinet in the garage There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water temperature measure 109.2 in residents’ bathroom faucet within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has a table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the garage and entrance. Facility has not hired new staff and has admitted new residents since COVID-19. Residents’ medications are stored locked in the kitchen and dining room cabinets. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Continued LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WILD FLOWERS RCFE	FACILITY NUMBER: 210111734
	VISIT DATE: 09/02/2021

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In addition, facility has a designated area for visitors which are being allowed. As per facilities visitors are only allowed outside through the entrance gate. Residents also have available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

In addition, LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills had been conducted quarterly last being done 7/2/2021. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).

LPAs reviewed Licensing Information System (LIS) with staff who stated that is correct and updated at this time.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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