216801993-4-19-2022-21-AS-CFGS-CDMPVF-20220419113904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801993
Report Date: 04/19/2022
Date Signed: 04/19/2022 11:41:35 AM

Document Has Been Signed on 04/19/2022 11:41 AM - 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:	CICADA-MILL VALLEY		FACILITY NUMBER:	216801993
ADMINISTRATOR:	NOEL CAMATOG		FACILITY TYPE:	735
ADDRESS:	309 ENTERPRISE CONCOURSE		TELEPHONE:	(415) 888-3880
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY: 6		CENSUS:	DATE:	04/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	DAniel Limpin - staff		TIME COMPLETED:	11:38 AM

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 Daniel Limpin. Administrator Noel Camatog was contacted by staff. Clients were present at the facility. Per staff only 1 client at this time is going to day program due to not enough staff at day programs. There are activities planned for clients during the day if they want to participate. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 4/19/2022 with staff Daniel Limpin 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 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 shed outside by the front door of the facility. LPA observed dangerous items such as several kitchen knives and scissors stored unlocked in a kitchen draw. (see pictures, LIC 809-D) Knives and scissors were locked during this visit in a freezer box, however; facility will need to find a more appropriated place for dangerous items. 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 121.2 degrees F and 125.7 degrees F in 3 out of 3 faucets falling out of Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted every six months with the last one being conducted on 1/07/2022. Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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: CICADA-MILL VALLEY	FACILITY NUMBER: 216801993
	VISIT DATE: 04/19/2022

NARRATIVE

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During annual required visit in 6/8/2021 and case management on 7/12/2021, Department requested documentation for new facility fire clearance due to addition in the back of the house and garage conversion that wasn’t present in prior facility fire clearance. Facility submitted update sketch with staff rooms and bathroom that has been added to garage conversion. Fire Marshall on 11/2/2021 submitted inspection clearance for a “three room, 6 patient facility” and did “not reviewed – garage conversion”. Department is requiring copy of permits that were needed for garage conversion which are being used at this time as staff rooms to ensure that facility has an appropriated fire clearance. Fire clearance on file at this time doesn’t clear staff rooms and bathroom which were part of the garage conversion.

Infection Control:
Facility has submitted a 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 living room/office area. There has been no new staff hired and/or new clients since COVID-19. Clients’ medications are stored and locked in medication closet in hallway area. 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 facility is working towards acquiring N-95 fit testing.

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.

Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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: CICADA-MILL VALLEY	FACILITY NUMBER: 216801993
	VISIT DATE: 04/19/2022

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Department is requesting Licensee to update the following documents and submit to CCL by 4/26/2022:

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
Copy of permits for garage conversion

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/19/2022 11:41 AM - It Cannot Be Edited

Created By: Carla Fernandes-Goes On 04/19/2022 at 11:06 AM

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: CICADA-MILL VALLEY	FACILITY NUMBER: 216801993
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 & interview,licensee did not comply with the section cited above in 1 out of 1 locked draw for dangerous items which poses an immediate health, safety or personal rights risk to persons in care.During tour of facility,LPA observed kitchen draw for dangerous items wasn't locking, and observed several knives and 2 scissors in a unlocked draw in the kitchen.
	POC Due Date: 04/20/2022
	Plan of Correction
1 2 3 4	Facility to ensure that all dangerous items are inaccessible to clients. Facility to lock dangerous items and make them inaccessible to clients and submit Department with self certification that items have been moved to an appropriated place by POC date of 4/20/2022.

Type A

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 client's bathroom faucets which poses an immediate health, safety or personal rights risk to persons in care. LPA observed hot water temperature measure between 121.2 degrees F and 125.7 degress F in 3 out of 3 clients' bathroom faucets.
	POC Due Date: 04/20/2022
	Plan of Correction
1 2 3 4	Facility to ensure that hot water temperature is in compliance with Title 22 Regulations of no less than 105 degrees F or more than 120 degrees F in client's faucets. Facility to submit a self certification by POC date of 4/20/22 that hot water temperature has been adjusted and 7-day hot water log by 4/26/22 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:

Bethany Moellers

LICENSING EVALUATOR NAME:

Carla Fernandes-Goes

LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

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