216803604-9-19-2023-21-AS-CFES-CVTTLN-20230919144948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803604
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:49:55 PM

Document Has Been Signed on 09/19/2023 02:49 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:	LONG LIFE LIVING INC III		FACILITY NUMBER:	216803604
ADMINISTRATOR:	CHANG, FAYE		FACILITY TYPE:	740
ADDRESS:	36 MT. FORAKER DRIVE		TELEPHONE:	(415) 479-4890
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator, Justine Herrera		TIME COMPLETED:	03:00 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	At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator, Justine Herrera. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 5 non-ambulatory and 1 bedridden resident for a total capacity of 6 residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 6 Residents in care and 3 staff on-site. At approximately 1:35PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:40PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 Resident bedrooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. During walk-through, LPA observed that hot water temperatures for 3 of 6 sinks in facility were out of Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 121.6F, 121.8F, and 123.6F (This deficiency has been cited, see LIC809D, Regulation 87303(e)(2)). Facility's fire extinguishers were last inspected August 2023. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted March 2023 (See Technical Violation, LIC9102, Health and Safety Code 1569.695(c)). At approximately 2:10AM, LPA reviewed staff files. Staff Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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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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: LONG LIFE LIVING INC III	FACILITY NUMBER: 216803604
	VISIT DATE: 09/19/2023

NARRATIVE

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Continued from LIC809

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, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 02:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LONG LIFE LIVING INC III	FACILITY NUMBER: 216803604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

(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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the Licensee did not comply with the section cited above in 3 of 6 sinks. LPA observed that facility's water temperatures measured 121.6F, 121.8F, 123.6F. This poses a potential health and safety risk to residents in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee to submit a water temperature log, documenting the Facility's water temperature for 7 days. Water temperature to be taken once in the morning and once in the afternoon. Temperature Log to include the following: date, time, sink location, and temperature. Log to be submitted to the Department for review and approval by POC due date of Friday, 09/29/2023.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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