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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 07/30/2021
Date Signed: 07/30/2021 02:04:00 PM

Document Has Been Signed on 07/30/2021 02:04 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CEDARS CARE HOME, THEFACILITY NUMBER:
286800667
ADMINISTRATOR:SHERWOOD, LAURAFACILITY TYPE:
740
ADDRESS:1520 CEDAR STREETTELEPHONE:
(707) 942-9200
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY: 12CENSUS: 10DATE:
07/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Irais Ortega LopezTIME COMPLETED:
02:10 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
Licensing Program Analyst (LPA) Angela Elliott arrived at 1:00 PM unannounced to conduct a case management regarding incidents occurring at the facility. LPA met with Irais Lopez Ortega, Administrator and requested copies of documentation.

Community Care Licensing (CCL) received incident report on 7/12/2021 for incident occurring on 7/1/2021 when R1 fell and hit the arm of the chair in their bedroom. R1 started bleeding and swelling on right side of their back. R1 indicated it hurt to breathe. Staff called Administrator who indicated staff should call Emergency Services. R1 was transferred to Saint Helena Hospital and diagnosed with right rib fractures, hemothorax and pneumothorax, traumatic. LPA and Administrator discussed reporting incidents within regulatory time frames. LPA provided Administrator copies of the regulations for 87211 Reporting Requirements.

CCL received an incident report on 7/21/2021 for an incident occurring on 7/20/2021. R2 pulled out their foley catheter during a shower. Staff bathed and dressed R2 and put them in the living room. When staff attempted to bring R2 to the breakfast table, they were non-responsive. Staff called Administrator who indicated staff should call 911. R2 was evaluated at Saint Helena Hospital, and admitted with a diagnosis of Urosepsis. LPA was notified R2 went on Hospice on 7/24/2021. Administrator indicated they thought Hospice notification to CCL was discontinued. Administrator was provided copies of 87633 Hospice Care of Terminally Ill Residents and 87465 Incidental Medical and Dental Care regulations.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and 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. Appeal rights given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2021
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 07/30/2021 02:04 PM - It Cannot Be Edited


Created By: Angela Elliott On 07/28/2021 at 03:30 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CEDARS CARE HOME, THE
FACILITY NUMBER: 286800667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2021
Section Cited
CCR
87465(g)

1
2
3
4
5
6
7
87465(g) Incidental Medical and Dental Care Services - 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to ensure that facility seeks immediate medical attention in a timely manner. Licensee/Administrator agrees to hold an in-service training with all staff regarding policy and procedures for seeking medical attention in a timely manner as incidents and/or observations arise. Plan for training date to be
8
9
10
11
12
13
14
Based on LPA observation, interviews and record review it was determined that staff did not seek medical attention in a timely manner for R1 and R2 which poses an immediate risk to the health, safety, and personal rights to residents in care.
8
9
10
11
12
13
14
submitted by COB 8/2/2021. Proof of training to be submitted to CCL by POC date of 8/13/2021.

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 Moellers
LICENSING EVALUATOR NAME:Angela Elliott
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2