216803606-9-19-2023-21-AS-CFES-CVTRR8-20230919131445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803606
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:14:53 PM

Document Has Been Signed on 09/19/2023 01:14 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 II		FACILITY NUMBER:	216803606
ADMINISTRATOR:	CHANG, FAYE		FACILITY TYPE:	740
ADDRESS:	15 PIKES PEAK DRIVE		TELEPHONE:	(415) 472-5876
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:	09:40 AM
MET WITH:	Administrator, Justine Herrera		TIME COMPLETED:	01:25 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 9:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Yazmin Ovilla. Adminstrator, Justine Herrera, arrived during visit at approximately 9:55AM. 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 2 staff on-site. At approximately 9:50AM, 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 10:00AM, 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, 2 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. During walk-through, LPA observed Lysol Disinfectant Spray located in a resident's bathroom. Facility staff immediately removed the disinfectant and locked it inaccessible to Residents in Care (This deficiency has been cited, see LIC809D, Regulation 87309(a)) LPA also observed that hot water temperatures for 2 of 4 sinks in facility were out of Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 121.3F and 120.7F (This deficiency has been cited, see LIC809D, Regulation 87303(e)(2)). LPA also observed that the facility's main kitchen had a magnetic lock. Per conversation with Administrator, the lock was put in place during COVID-19 to prevent residents from over-eating at night time. LPA informed Administrator that a waiver request needs to be submitted to the Department for review and approval if they wish to have a locked fridge. Administrator stated that they will remove the lock since it is no longer necessary. Administrator stated that they understood if they wanted to have a lock on the fridge in the future, than a waiver request and its supporting documents would need to be submitted to the Department. LPA observed Administrator remove the magnetic lock from the main fridge during visit. 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 II	FACILITY NUMBER: 216803606
	VISIT DATE: 09/19/2023

NARRATIVE

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Continued from LIC809

At approximately 10:50AM, LPA reviewed staff files, resident files and resident medications. All Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification.

Facility's fire extinguishers were found to be last inspected August 2023. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted January 2023 (See Technical Violation, LIC9102, Health and Safety Code 1569.695(c)).

LPA is requesting the following documents to update facility file:

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance
Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 10/19/2023.

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 01:14 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 II	FACILITY NUMBER: 216803606
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

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 LPA observation, the Licensee did not comply with the section cited above. LPA observed a can of Lysol Spray located in a Resident’s bathroom that was accessible to Residents in Care. This poses a potential health and safety risk to residents in care. LPA observed that Facility Staff immediately placed Lysol Spray in the Facility's locked toxins storage area.
	POC Due Date: 09/20/2023
	Plan of Correction
1 2 3 4	Licensee to submit a new cleaning procedure to Department by POC due date of 09/20/2023. Licensee to submit In-Service Training Log to Department on Facility’s new procedure for review and approval by POC due date of Friday, 09/29/2023. In-Service Training Log to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures.

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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Document Has Been Signed on 09/19/2023 01:14 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 II	FACILITY NUMBER: 216803606
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 LPA observation, the Licensee did not comply with the section cited above in 2 of 4 sinks. LPA observed that facility's water temperatures measured 120.7F and 121.3F. 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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