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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804090
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:26:17 PM

Document Has Been Signed on 07/12/2024 03:26 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:OCEANFRONT CARE HOME LLCFACILITY NUMBER:
236804090
ADMINISTRATOR/
DIRECTOR:		NGAIMA, MAMAFACILITY TYPE:
740
ADDRESS:1370 NAVARRO BLUFF ROADTELEPHONE:
(707) 877-1698
CITY:ALBIONSTATE: CAZIP CODE:
95410
CAPACITY: 6CENSUS: 5DATE:
07/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Issac RolleTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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At approximately 1:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to complete the Required-1 Year inspection which was started on 05/03/2024. LPA met with House Manager Issac Rolle and reviewed records. LPA reviewed 4 of 4 resident records. LPA observed 2 of 4 residents care plans were last updated June of 2023. LPA advised Issac to update as needed or at least every 12 months. 1 of 4 resident physician reports were not updated within the last 12 months. LPA advised Issac to ensure residents with a dementia diagnosis need to have physician reports updated at least every 12 months.

At approximately 2:00PM, LPA reviewed 2 of 2 staff records. Staff files contained documentation of completed annual training and current first aid/CPR certification.

While conducting a complaint investigation, LPA observed facility placed a bedridden resident in a room not cleared as a bedridden room. Local fire department personnel were required to remove the door to get resident out of the room. Facility has two rooms cleared for bedridden residents, however this room was not. An immediate civil penalty is being issued in the amount of $500 for this fire clearance violation.

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 Issac Rolle and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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 07/12/2024 03:26 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 07/12/2024 at 03:06 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: OCEANFRONT CARE HOME LLC
FACILITY NUMBER: 236804090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
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: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and a record review, the licensee did not comply with the section cited above in one out of four residents. Bedridden resident was placed in a non ambulatory room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Resident moved from facility. POC cleared at time of visit
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
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