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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803891
Report Date:
04/23/2024
Date Signed:
04/23/2024 03:23:39 PM
Document Has Been Signed on
04/23/2024 03:23 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
ADMINISTRATOR/
DIRECTOR:
THOMAS EISEMAN
FACILITY TYPE:
740
ADDRESS:
297 MILLER AVE
TELEPHONE:
(415) 388-9526
CITY:
MILL VALLEY
STATE:
CA
ZIP CODE:
94941
CAPACITY:
49
TOTAL ENROLLED CHILDREN:
0
CENSUS:
26
DATE:
04/23/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:
Erlinda Ferris (Acting Administrator)
TIME VISIT/
INSPECTION COMPLETED:
03:38 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Rummonds made an unannounced required annual inspection of this facility and met with facility acting Administrator Erlinda Ferris. Annual fees current.
LPAs/Administrator toured the building and grounds which was found to be clean and in good repair. The main building is two stories and currently there are seven residents residing upstairs. Second building is single story and currently there are two residents. At approximate 10am LPAs/Administrator did not observe assigned staff in the second building providing care and supervision to resident in care who has a non-ambulatory status as indicated in their facility plan of operation. Assigned staff was walking into the second building as we were touring the facility. LPAs reminded the Administrator the requirement to have an assigned staff at all times in the second building to assist residents in care. Administrator could not provide a reasonable explanation regarding the absence of assigned staff in the second building. Medication is centrally stored and locked in medication cart and closet. A sample of medication and medication records reviewed. Facility has cameras is both buildings in common areas. However, at approximate 10:05am LPAs/Administrator observed cameras located in private room #2 and 26. Per Administrator, resident's responsible parties brought the cameras without permission. LPAs/Administrator also smelled several bathrooms has a strong urine odor. LPAs/Administrator did not observe any CCL's reports placed in a conspicuous place. Also, the facility does not have required CCL complaint poster. A technical violation will be issued.
At approximate 10:30am LPAs/Administrator observed hot water measurements of 129.3, 132, 145.2, 136 and 146.8 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care. Fire extinguishers inspected were charged and dated 4/5/2024. Smoke detectors were tested in resident rooms. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. The last disaster drill was conducted on September 27, 2023.
Continued on LIC809C...
Bethany Moellers
TELEPHONE:
(707) 588-5040
Marisol Cuadra
TELEPHONE:
(707) 588-5078
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation, the licensee did not comply with the section cited above in 5 out of 5 sinks accessible to residents in care which poses an immediate health and safety risk to persons in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agrees submit a self certification stating that they turned down water heater by POC due date of 4/24/2024. Administrator agrees to submit a daily hot water temperature log for all sinks used by residents for the week of 4/242024 through 05/01/2024. Temperature log to be submitted to CCL by 05/02/2024.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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 5 out of 5 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit a plan which addresses how facility will ensure staff are receiving required initial and annual training and how hours will be tracked. Plan to be submit to CCL by POC due date of 4/24/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)
Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
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 by having cameras in 2 residents bedrooms which poses an immediate personal rights risk to persons in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agrees to contact responsible parties to remove cameras from both residents rooms and submit self certification stating that cameras have been removed to CCL by POC due date of 4/24/2024
Request Denied
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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 by having expired canned foods which poses an immediate health risk to residents in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agress to develop and implement a system which will address how they will ensure to properly store food to ensure quality of food and safety of residents. Administrator will submit written policy as proof of correction to CCL by POC due date of 04/24/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87705(c)(4)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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 by not having staff in back cottage while resident(s) were in the building which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit a plan to CCL which addresses how they will ensure a staff is in the back cottage at all times by POC due date of 04/24/2024. Administrator agrees to hold an all staff meeting by 05/15/2024 that covers why there must be staff in back cottage at all times, and how they will implement the policy. Meeting conducted must have a sign in sheet with names, dates, and signatures, as well as the topics covered in meeting.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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 by leaving the door unlocked to the laundry room which stores toxic substances which poses an immediate health and safety risk to persons in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit a plan to CCL which addresses how they will ensure toxic substances are stored inaccessible at all times by POC due date of 04/24/2024. Administrator agrees to hold an all staff meeting by 05/15/2024 that includes why facility must store toxic substances inaccessible, and how they will implement the policy. Meeting conducted must have a sign in sheet with names, dates, and signatures, as well as the topics covered in meeting.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
4
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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 by having exit doors not equipped with auditory devices which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/24/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit self certification stating how they are going to ensure that all exit doors are going to remain equipped with auditory devices and maintained in operating condition. Administrator agrees to test all exit doors and replace any alarms that are inoperable. Self certification to be submitted to CCL by POC due date of 04/24/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.
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 which poses a potential health risk to persons in care.
POC Due Date:
05/01/2024
Plan of Correction
1
2
3
4
Administrator agrees to purchase waste bins with tight fitting covers and replace all waste bins without covers by POC due date of 05/01/2024. Proof of purchase to be submit to CCL by 05/01/2024.
Request Denied
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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 4 out of 5 staff records reviewed which poses a potential health and safety risk to persons in care.
POC Due Date:
05/01/2024
Plan of Correction
1
2
3
4
Administrator agrees to audit all staff CPR/First Aid training records and finalize which staff needs an updated CPR/First Aid on file. Administrator agrees to send updated First Aid/CPR for S1, S2, S3, S4, and S5 to CCL by POC due date of 04/23/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
6
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
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 2 out of 5 staff which poses a potential health and safety risk to persons in care.
POC Due Date:
05/01/2024
Plan of Correction
1
2
3
4
Administrator agrees to audit staff records and determine which staff are missing a health screening report, and submit health screenings for S1 and S2 to CCL by POC due date of 05/01/2024.
Request Denied
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 5 of 5 residents (R1, R2, R3, R4 and R5) who needs their care plan to be updated, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/08/2024
Plan of Correction
1
2
3
4
Licensee to update and complete resident's Needs & Services Plan, with appropriate signatures of Administrator and resident's responsible party by POC due date of 05/08/2024. Facility to submit self certification ensuring compliance with regulation to CCL by POC due date of 5/08/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
7
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/01/2024
Plan of Correction
1
2
3
4
Licensee to provide proof of disaster drill being conducted by POC due date of 05/01/2024.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
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 by having residents whose beds are equipped with half rails without physicians orders on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/08/2024
Plan of Correction
1
2
3
4
Administrator agrees to get bed rail orders for all residents who require a bed rail. Proof of physicians orders to be provided to CCL by POC due date of 05/08/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
8
of
12
Document Has Been Signed on
04/23/2024 03:23 PM
- It Cannot Be Edited
Created By:
Marisol Cuadra
On
04/23/2024
at
01:50 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:
MARIN TERRACE
FACILITY NUMBER:
216803891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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 by not ensuring that the facility remains free from odors from incontinence which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/01/2024
Plan of Correction
1
2
3
4
Administrator agrees to submit self certification stating that they reviewed the regulation as well as how they will ensure compliance by POC due date of 05/01/2024
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/01/2024
Plan of Correction
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2
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Administrator agrees to update residents (R1, R2, R3, R4, R5) medical assessments, by POC due date of 05/08/2024. Facility to submit self certification stating how they will ensure compliance with regulation to CCL by POC due date of 5/08/2024.
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:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
9
of
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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:
MARIN TERRACE
FACILITY NUMBER:
216803891
VISIT DATE:
04/23/2024
NARRATIVE
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Continued from LIC809...
Residents have emergency pull cords in restrooms, call buttons at bed side and facility uses Wander Guard alert system. All auditory devices sound in the kitchen and light indicated alert in Administrator office. The amount of fresh and nonperishable foods is within regulation. LPA toured the kitchen and dinning areas. At 10:45 AM LPAs/Administrator observed expired canned goods, unpacked dry good not with expiration dates noted in the food pantry storage and unlocked laundry room with toxins and cleaning supplies accessible to residents in care. Also, LPAs/Administrator did not observe any auditory alarm on the second story door located in the main building, which leads to steep stairs. Hoyer lift used for residents in care was tested and it was found operational during the visit. However, staff observed might receive additional training to operate this type of equipment. A discussion with Administrator was handled to explain the importance of staff having better knowledge in how to operate the hoyer lift equipment properly.
LPAs initiated file review at 11am. Five residents and five staff files were reviewed. Four out of five staff (S1, S2, S3 and S4) did not have a current CPR/1st aid on file. Two out of five staff (S1 and S2) do not have a health screening including TB test on file. Five out of five staff (S!, S2, S3, S4 & S5)do not have required annual training hours completed on file. Five out five residents (R1, R2, R3, R4 & R5) who has a diagnosis of dementia need an updated medical assessment and care plan. Several residents have half bed rails, but they do not have a doctor's order on file for use of half bed rails. Per Administrator, they had been working with resident's physician to obtain one for each of them. Administrator certificate for administrator Erlinda Ferris 6054488740 expires on 12/8/25.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection:
LIC500- Personnel Report.
LIC308- Designation of Responsibility.
LIC610E- Disaster Plan.
Evidence of Liability Insurance.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.
Exit interview was conducted with Administrative assistant who was informed that
the Department will be reviewing if further action is needed to address the overall compliance of the facility
and a copy of this report was given.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5040
LICENSING EVALUATOR NAME:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/23/2024
LIC809
(FAS) - (06/04)
Page:
12
of
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