216800895-6-23-2021-21-AS-SHAN-C49U6W-20210623151901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800895
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:19:14 PM

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:	ANTON POINTE, THE		FACILITY NUMBER:	216800895
ADMINISTRATOR:	ODIWE, CLEDA M.		FACILITY TYPE:	740
ADDRESS:	1470 SOUTH NOVATO BLVD.		TELEPHONE:	(415) 897-1055
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	10	CENSUS: 6	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee Cleda Odiwe		TIME COMPLETED:	03:20 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 Analysts (LPAs) Shannan Hansen & Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Licensee Cleda Odiwe. There were six residents present at the time of the visit. LPAs toured the facility with Licensee Cleda Odiwe at 1:30 PM. During facility tour with licensee Odiwe 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 found to be last charged on 6/2019 at the time of the visit (LIC809-D). A sample of 1 out of 1 Smoke Detectors was in working order although 1 out of 1 Carbon monoxide detector was found to be non-operational during the visit (LIC809-D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Toxins are stored locked in a bin in the laundry room. 1 out of 2 hot water temperatures measured 77.8 degrees F(LIC809-D). failing out of Title 22 acceptable regulations of 105 ro 120 degrees F in 1 of 2 resident's bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings Infection Control: Facility has submitted a mitigation program plan that has been submitted awaiting approval at this time with CNA. Posters have been placed at facility with exception of coughing etiquette and COVID symptoms which LPA will be providing to the facility. Facility has PPE supply stored in the hallway closet by the entrance door and in the office. Clients’ medications are stored and locked in a file cabinet in the office. Facility has a 30-day supply of medication for clients. Per Licensee staff had all PPE training required although did not have proof on file and LPAs requested copy for file. Licensee still working towards acquiring N-95 fit testing. Continue LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: ANTON POINTE, THE	FACILITY NUMBER: 216800895
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 1 out of 1carbin minoxide not working properly during testing while touring of facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2021
	Plan of Correction
1 2 3 4	Facility to ensure that there is 1 function carbon minoxide at the facility at all times. Facility to send senf certification that facility has 1 functioning carbin minoxide detector (998).

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 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 1 out of 2 faucets which poses/posed a potential health, safety or personal rights risk to persons in care. After arrival during tour of facility, LPAs tested hot water temperature on both bathroom faucets for the residents and learned that one of the faucets temperture reading was 77.8 degrees F. below acceptable hot water temperature.
	POC Due Date: 07/07/2021
	Plan of Correction
1 2 3 4	Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Facility to adjuste hot water temperature and submit a 7 day log by POC due date of 7/7/2021 in order to clear this citation.

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: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ANTON POINTE, THE	FACILITY NUMBER: 216800895
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marchal for the protection of life and property against fire and panic. 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 2 out of 2 fire extinguishers,which were last inspected on 6/2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2021
	Plan of Correction
1 2 3 4	License to ensure facility adhers to current fire safety regulations at all times. Licensee to ensure fire extinguishers are servised on an annual basis. License to submit to CCL proof of servicing by POC due date of 7/7/2021 in order to clear this violation.

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: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: ANTON POINTE, THE	FACILITY NUMBER: 216800895
	VISIT DATE: 06/23/2021

NARRATIVE

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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents have available telephone calls when contacting with family members and others.

Per licensee fire drill was conducted last 1/2021 however facility has no proof of disaster drill and or log.

LPAs reviewed Licensing Information System (LIS) with licensee who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

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.

Department is requesting the following documents to be submitted to CCL by 7/7/2021:

LIC 308
LIC 500

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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