216801923-11-6-2023-21-AS-HRUS-CXBT9C-20231106133142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801923
Report Date: 11/06/2023
Date Signed: 11/06/2023 01:32:20 PM

Document Has Been Signed on 11/06/2023 01:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	YOUNG AT HEART RCFE		FACILITY NUMBER:	216801923
ADMINISTRATOR:	ROMUALDOFORTEZ,BELLANACHOR		FACILITY TYPE:	740
ADDRESS:	37 MENDOCINO LANE		TELEPHONE:	(415) 209-6185
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	6	CENSUS: 6	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Romualdo Fortez		TIME COMPLETED:	01:45 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) Helena Rummonds and Licensing Program Manager (LPM) Bethany Moellers arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Romualdo Fortez arrived at a later time. LPA initiated a tour of the facility around 9:10am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. LPA observed poisons unlocked in laundry area (various cleaning supplies), in an open garage (windex, WD-40), as well as outside (paint can, gallon of simple green) in areas accessible to residents (deficiency cited). LPA requested administrator secure observed toxins immediately. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked with the key remaining in the lock. Medications were pre poured for the day. Per conversation with administrator, facility is to keep the keys in a separate area inaccessible to residents, and administrator agrees to immediately stop pre pouring medications. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment. Fire extinguishers were last serviced May 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 09/18/2023. Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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 11/06/2023 01:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: YOUNG AT HEART RCFE	FACILITY NUMBER: 216801923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/07/2023
	Plan of Correction
1 2 3 4	Administrator to submit date of all staff training on storage of toxic substances by POC due date of 11/07/2023, and to submit proof of staff training by POC due date of 11/20/2023.

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) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/06/2023 01:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: YOUNG AT HEART RCFE	FACILITY NUMBER: 216801923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

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 record review, the licensee did not comply with the section cited above in 3 out of 6 persons which poses a potential health risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee to submit proof of TB test for R1, R2, & R3 to CCL by POC due date of 11/27/2023.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit proof of an updated care plan for R4 & R5, and a signature on care plan for R1 by POC due date of 11/13/2023.

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) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: YOUNG AT HEART RCFE	FACILITY NUMBER: 216801923
	VISIT DATE: 11/06/2023

NARRATIVE

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Continued from LIC809

Five staff files and six resident files were reviewed. 3 of 6 resident (R1, R2 & R3) records did not have record of TB tests. 2 of 6 residents (R4, R5) did not have an up to date care plan, and 1 of 6 residents (R1) did not have a signed care plan (deficiency cited). Staff have required First Aid and CPR certificates. Training records were reviewed. Administrative Certificate for Administrator, Romualdo Fortez, 6015496740 is up to date and expires 06/10/2024. Medications and medication records were reviewed. During medication record review, LPA observed that PRN medications are not being documented per regulation. Per conversation with administrator, PRN medications will be documented per regulation.

During today's inspection LPM and LPA were noticed that the licensee is seeking to find another individual to take over and submit an application to the Department or close of the facility. LPM spoke to Domingo Ramos and confirmed a letter was provided to responsible parties on 9/29/2023 informing of this intent. Ramos agrees to update LPA Rummonds by 11/9/2023 of intent of closure and current status of LLC.

Licensee/Administrator to submit updates of the following documents by 12/06/2023:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If any changes)
Infection Control Plan (If any changes)

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, LIC809D, LIC 811, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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