216803982-10-12-2023-21-AS-CFES-CWJUL5-20231012154009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803982
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:40:22 PM

Document Has Been Signed on 10/12/2023 03:40 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:	ANTON POINTE, THE		FACILITY NUMBER:	216803982
ADMINISTRATOR:	ODIWE, CLEDA M.		FACILITY TYPE:	740
ADDRESS:	1470 SOUTH NOVATO BLVD.		TELEPHONE:	(415) 897-1055
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	10	CENSUS: 8	DATE:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator/Licensee, Cleda Odiwe		TIME COMPLETED:	02:30 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 9:15AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a Required 1-Year visit and met with Administrator, Cleda Odiwe. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 10 non-ambulatory residents. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPAs were informed that there were currently 8 residents in care and 3 staff members on-site. At approximately 9:30AM, LPAs 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 9:45AM, LPAs conducted a walk-though of the facility and observed the following: Facility is a 1 story building with 6 Resident bedrooms, 2 bathrooms, and common spaces. Facility had emergency lighting. 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. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPAs observed a structure on the property not identified on facility's sketch. Investigation of the structure indicated that it is a two room structure. LPAs observed that one room is for storage, and the other is a living unit. Per conversation with Administrator, they sleep there when they decide to spend the night at the facility and the structure has been there since the facility was opened in 2001 (pictures of structure taken). During walk-through, LPAs observed the following deficiencies: Cleaning products and supplies located in residents' bathroom were unlocked and accessible to residents in care. Knives and other sharps were unlocked in a drawer accessible to residents in care (These deficiencies have been cited, see LIC809D, Regulation 87705(f)(1) and Regulation 87705(f)(2)). Three facility exits were obstructed by resident belongings in 2 of 6 bedrooms, and in the living room. LPAs saw a night stand and lamp obstructing the exit sliding door in Bedroom 1, a night stand, lamp, and dresser obstructing the exit sliding door in Bedroom 5, and a resident's walker obstructing the exit door to the backyard in the living room (This deficiency has been cited, see LIC809D, Regulation 87202(a)), and LIC421IM). 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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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 10/12/2023 03:40 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: ANTON POINTE, THE	FACILITY NUMBER: 216803982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed 3 of 5 exits obstructed by resident belongings. Bedroom 1's exit was obstructed by a night stand and lamp, Bedroom 5's exit was obstructed by a night stand, lamp, and dresser, and Facility's living room exit was obstructed by an assistive walking device. Facility immediately moved items. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Fire Clearance 87202(a). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 10/13/2023, and Training to be submitted by due date of 10/22/2023.

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 LPAs observations, the Licensee did not comply with the section cited above. LPAs observed expired food cans in the pantry, and and expired yogurt, moldy sausages, and unlabelled and uncovered meals in facility fridges. LPAs observed Facility staff immediately discard expired and moldy food. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Food Services 87555(b)(8). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 10/13/2023, and Training to be submitted by due date of 10/22/2023.

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 03:40 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: ANTON POINTE, THE	FACILITY NUMBER: 216803982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed the following: construction items discarded by the side of the house, mold located on house exterior, wood rot on roof, facility ceiling observed to be caving in, bathroom tiles were moldy and in need of replacement. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2023
	Plan of Correction
1 2 3 4	Licensee to remove all identified items by the side of the house and to clean and repair mold, tiles, and living room ceiling. Licensee to submit proof of repairs to CCL by POC due date of 10/22/2023.

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 03:40 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: ANTON POINTE, THE	FACILITY NUMBER: 216803982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed knives and other sharp objects in an unlocked drawer in the kitchen accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 10/13/2023, and Training to be submitted by due date of 10/22/2023.

Type A

Section Cited

CCR

87705(f)(2)

87705 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 LPAs observations, the Licensee did not comply with the section cited above. LPAs observed cleaning supplies and toxins in residents' bathroom that were unlocked and accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(2). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 10/13/2023, and Training to be submitted by due date of 10/22/2023.

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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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: ANTON POINTE, THE	FACILITY NUMBER: 216803982
	VISIT DATE: 10/12/2023

NARRATIVE

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Continued from LIC809

LPAs saw expired food cans and yogurt, moldy sausages, and unlabelled and uncovered meals in fridge. Facility staff immediately discarded expired and moldy food (This deficiency has been cited, see LIC809D, Regulation 87555(b)(8)).
LPAs observed feces and a soiled disposable pad in a resident's bedroom. The bedroom also had a strong smell of urine. During visit, LPAs observed facility staff clean the bedroom and replace the bed pad. LPAs observed that there was no longer a smell of urine. LPAs observed a pile of discarded items including wood, nails, caulk, and cardboard located on the side of the facility. LPAs also saw mold located on the exterior of the house, wood rot on the roof, facility's living room ceiling was observed to be caving in and the tiles in Bathroom 1 were moldy and were in need of replacing. LPAs saw that the bottom bathroom tiles were shown to be broken and peeling off from the wall (pictures of disrepair and items to be discarded taken) (This deficiency has been cited, see LIC809D, Regulation 87303(a)).

LPAs unable to complete Required 1-Year/Annual visit. Annual Continuation Visit to be conducted at a later date.

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.

***An immediate civil penalty in the total amount of $500.00 has been issued for being out of compliance with fire clearance regulation 87202(a).

Exit interview conducted. Copy of report, LIC809D, LIC421IM, 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: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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