236803976-12-26-2023-21-AS-CARD-CYVT53-20231226132453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 236803976
Report Date: 12/26/2023
Date Signed: 12/26/2023 01:25:05 PM

Document Has Been Signed on 12/26/2023 01:25 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:	CANYON VIEW SENIOR HOME CARE II		FACILITY NUMBER:	236803976
ADMINISTRATOR:	PRAIPHETSAK, WIROTE		FACILITY TYPE:	740
ADDRESS:	831 CYPRESS AVE		TELEPHONE:	(707) 234-9428
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	4	CENSUS: 4	DATE:	12/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Will Praiphetsak		TIME COMPLETED:	01:40 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 10:10AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Will Praiphetsak. At approximately 10:15AM, 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. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins were observed unsecured under the resident restroom sink. 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 11:00AM, LPA reviewed 4 of 4 resident records and found 3 of 4 residents did not have current physician's reports. Two of 4 records did not contain current care plans. 4 of 4 records contained current and signed admission agreements and physician's orders. At approximately 12:30PM, LPA reviewed 4 staff records. 4 of 4 records contained evidence of required training. Evidence of current first aid and CPR training were current. Continued on LIC 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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: CANYON VIEW SENIOR HOME CARE II	FACILITY NUMBER: 236803976
	VISIT DATE: 12/26/2023

NARRATIVE

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At approximately 12:45PM, LPA reviewed the facility emergency disaster plan. 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. Facility conducts disaster drills monthly.

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

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 Will Praiphetsak 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: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/26/2023 01:25 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: CANYON VIEW SENIOR HOME CARE II	FACILITY NUMBER: 236803976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

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 observation, the licensee did not comply with the section cited above. LPA observed cleaning solutions stored under resident bathroom sink, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	Licensee to ensure cleaning solutions and toxins are not accessible to residents. Licensee removed the items immediately. POC cleared at time of visit.

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: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/26/2023 01:25 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: CANYON VIEW SENIOR HOME CARE II	FACILITY NUMBER: 236803976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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. Licensee did not have Liability insurance, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	Licensee to submit evidence of liability insurance to CCL by POC date of 1/26/2024.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the 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 3 of 4 resident records. Physician reports were not updated within last 12 months. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certifiction that physician reports have been updated. Self certifiation to be submitted to CCL by POC date of 1/26/2024.

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: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/26/2023 01:25 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: CANYON VIEW SENIOR HOME CARE II	FACILITY NUMBER: 236803976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

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 records reviewed, the licensee did not comply with the section cited above in 2 of 4 resident records, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certification that resident appraisals are updated. Self certification to be submitted to CCL by POC date of 1/26/2024.

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: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

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