<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801775
Report Date: 01/19/2024
Date Signed: 01/19/2024 12:46:36 PM


Document Has Been Signed on 01/19/2024 12:46 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:EQUINOX CARE FACILITY LLCFACILITY NUMBER:
236801775
ADMINISTRATOR:AJEL, AGNESFACILITY TYPE:
740
ADDRESS:38281 S HWY 1TELEPHONE:
(707) 884-4061
CITY:GUALALASTATE: CAZIP CODE:
95445
CAPACITY:9CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Agnes AjelTIME COMPLETED:
01:00 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 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit to follow up with facility regarding a previous request for a bedridden fire clearance. Prior to this visit, LPA met with the Fire Department to discuss modifications needed prior to the approval of the request. LPA met with Administrator Agnes Ajel and reviewed the items requested by the fire department. Due to the time frames involved for the required additions, Agnes has agreed to retract the request at this time and will resubmit when the additions are complete. The facility, LPA and Fire Department will work together to formulate a plan, with time frames of completion, for the additions needed to allow facility to re-apply for the clearance. The following items will be outlined in the plan:
- Integrated fire system, including audio/visual alerts, sprinklers and pull stations
- widening of doorways
- fire doors
- ensuring exit paths are wide enough for emergency personnel
These items are not intended to be a complete list of requirements, as there may be more items found that need to be addressed.

LPA discussed the facilities disaster plan and disaster drills. The facility has not been compliant with conducting drills as required. LPA requested an updated disaster plan, which describes how facility staff will safely evacuate residents, including bedridden residents, in case of an emergency. LPA provided regulation 87212 and 87606 for review.

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.

This report was reviewed with Agnes Ajel and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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 2


Document Has Been Signed on 01/19/2024 12:46 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: EQUINOX CARE FACILITY LLC
FACILITY NUMBER: 236801775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87705(k)(3)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia: (k)(3)Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met
1
2
3
4
5
6
7
Licensee will draft an updated disaster plan, which shall provide detail for each item listed in Regulation 87212. In addition, Licensee will train all staff on updated plan and conduct as drill. Written plan
8
9
10
11
12
13
14
as evidenced by: Based on interviews conducted, Licensee is not conducting drills as required. This poses a potential Safety risk to residents in care.
8
9
10
11
12
13
14
and evidence of completed staff training and evidence of completed drill will be submitted to CCL by POC date of 01/31/2024.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2