236803819-6-12-2023-21-AS-CARD-CSQP42-20230612105824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 236803819
Report Date: 06/12/2023
Date Signed: 06/12/2023 10:58:30 AM

Document Has Been Signed on 06/12/2023 10:58 AM - 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:	VICTORIA MANOR		FACILITY NUMBER:	236803819
ADMINISTRATOR:	REYES, VICTORIA		FACILITY TYPE:	740
ADDRESS:	419 GROVE ST		TELEPHONE:	(707) 456-1234
CITY:	WILLITS	STATE: CA	ZIP CODE:	95490
CAPACITY:	6	CENSUS: 6	DATE:	06/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Victoria Reyes		TIME COMPLETED:	11:15 AM

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 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Victoria Reyes. At approximately 8:45AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 9:15AM, LPA reviewed 6 resident records and found 6 of 6 residents did not have current physician's reports. 3 or 6 residents did not have current appraisals. 6 of 6 records contained current and signed admission agreements and physician's orders. Medication records are thorough and contained physician's orders for each resident. At approximately 10:00AM, LPA reviewed 3 staff records. 3 of 3 records did not contain documentation of completed training as required. Evidence of current first aid and CPR training were current. LPA provided documentation regarding the required annual training to Licensee. Continued on LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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 4

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: VICTORIA MANOR	FACILITY NUMBER: 236803819
	VISIT DATE: 06/12/2023

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
26
27
28
29
30
31
32

At approximately 10:30AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
Evidence of Liability Insurance

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 Victoria Reyes and Appeal rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/12/2023 10:58 AM - 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: VICTORIA MANOR	FACILITY NUMBER: 236803819
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 records reviewed, the licensee did not comply with the section cited above in 3 of 3 staff files reviewed. Records did not contain documentation of completed training. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee to ensure staff receive at least 20 hours of ongoing training. Licensee to submit self certification that staff have received at least 20 hours of ongoing training and Licensee has documented the training.

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in 6 of 6 resident records. Records did not contain current physician reports. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee to ensure residents have updated medical assessments at least every 12 months. Licensee to submit self certification that medical assessments have been completed.

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: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/12/2023 10:58 AM - 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: VICTORIA MANOR	FACILITY NUMBER: 236803819
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 3 of 6 resident records. Licensee did not have updated appraisals.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee to update resident appraisals as needed or at least every 12 months. Licensee to submit self certification that appraisals have been updated.

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: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4