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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803269
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:40:40 PM

Document Has Been Signed on 05/15/2023 02:40 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:RIVERLAND PLACEFACILITY NUMBER:
216803269
ADMINISTRATOR:BENOIT, WILSONFACILITY TYPE:
735
ADDRESS:49 PICO VISTATELEPHONE:
(415) 756-5525
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 5DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Wilson Benoit, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced annual 1 year required inspection to this facility and was welcome by Administrator Wilson Benoit. There are 5 clients at the facility 4 of which left shortly after LPA arrival.

LPA toured the facility on 5/15/2023 at 11:40 AM with Licensee/Administrator Wilson Benoit; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA toured the facility building and grounds which was found to be clean and in good repair. Fire Extinguisher was found to be last charged on 5/15/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 113.3 & 122.9 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 3 client’s bathrooms while touring facility on 5/15/2023 at 11:50 AM. Licensee immediately decreased thermostat on water heater. 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 cabinet inside facility kitchen. Dangerous items were stored inaccessible to develop disabled clients, while touring the facility with Licensee/administrator Wilson Benoit. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All five client’s bedrooms have lighting & appropriate furnishings on 5/15/2023 at 12:05 PM.

A review of five clients and sample review of three staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 12:30 PM on 5/15/2023 and learned that 5 of 5 clients have an updated reappraisal/needs & care plan, as well as Medical Assessment. P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for 3 out of 5 client’s P&I; facility had P& I and ledgers available during the visit. P& I money not comingled, and ledgers are current at this time.



Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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 05/15/2023 02:40 PM - It Cannot Be Edited


Created By: Shannan Hansen On 05/15/2023 at 02:16 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: RIVERLAND PLACE
FACILITY NUMBER: 216803269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above in 1 of 3 clients bathroom water faucets measured 122.9 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Licensee assessed water heater tempterature during annual inspection. LIcensee to submit 7 day log of water temperature in that client bathroom and submit to CCL by 5/22/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RIVERLAND PLACE
FACILITY NUMBER: 216803269
VISIT DATE: 05/15/2023
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Medications were centrally stored in a locked cabinet in the facility office area/living room. LPA conducted a sample audit of medications. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 5/15/2023. Centrally Stored Medication Records (CSMR) on 5/15/2023 were accurate for both clients in the facility.

LPA conducted a sample review of staff records and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received training. LPA was presented with proof of CPR & 1st Aid certification for staff records that were reviewed. Wilson Benoit Administrator Certificate # 6006356735 expires on 1/31/2025. Disaster drills are conducted every six months with the last dated 1/10/2023.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents.



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.

LPA is requesting the following documents in order to update facility file to be submitted to CCL by 6/9/2023:

LIC 308 Designated (only if changing)
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan (if no change – just signed back page)
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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