286800667-12-21-2021-21-AS-KLOZ-C9X4GY-20211221180619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 12/21/2021
Date Signed: 12/21/2021 06:06:31 PM

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, THE		FACILITY NUMBER:	286800667
ADMINISTRATOR:	LOPEZ, PAULINA		FACILITY TYPE:	740
ADDRESS:	1520 CEDAR STREET		TELEPHONE:	(707) 942-9200
CITY:	CALISTOGA	STATE: CA	ZIP CODE:	94515
CAPACITY:	12	CENSUS: 9	DATE:	12/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Paulina Lopez, Administrator		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Required- 1 year annual inspection and met with Viridiana Agapoff, House Manager and Administrator, Paulina Lopez. The annual inspection was focused on the Infection Control procedures and practices. LPA conducted risk assessment with House Manager. Administrator Paulina Lopez arrived later. LPA conducted a walk-through of the facility with House Manager. Fire Extinguishers were found to be last charged on August 3rd, 2021. There was sufficient amount of supply for both perishable and nonperishable foods. A sample of Smoke & Carbon monoxide detectors were tested and operational during visit. LPA observed COVID-19 precaution postings. LPA temperature was taken and documented on sign-in sheet. LPA advised facility to ask screening questions for all visitors, residents and staff at entrance. Visitors and staff and residents temperatures are being documented for COVID-19 symptoms upon arrival to the facility. Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility at least once daily. Some staff have completed training on infection prevention, symptoms, transmission and PPE use but will schedule training for the remaining staff. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was approved by the California Department of Social Services on 3/16/21. During the walk through of facility, LPA observed Resident #1 (R1) room and bathroom used partially used as a storage (photos taken). House Manager stated that they were storing Christmas supplies in R1's room. R1's bathroom tub had a toilet seat, walker and other materials (photos taken). LPA also observed restroom shower by the washer machines with a hamper inside shower. House Manager stated that facility uses the shower to put laundry in (photos taken). Continue to LIC 809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 286800667
	VISIT DATE: 12/21/2021

NARRATIVE

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House Manager stated that facility does not use that shower for residents. LPA observed two scissors that were accessible to residents in care and were immediately put away by House Manager. At approximately 9:43am, LPA observed toxins with lock that was unlocked and House Manager immediately locked the cabinet. House Manager stated that staff had finished cleaning. At 9:38am, LPA observed one alcohol bottle in refrigerator by resident rooms that was accessible to residents in care. House Manager stated that the alcohol was for R2. R2 drinks some alcohol during the week. House Manager agreed to lock alcohol at all times. House Manager threw away bottle of alcohol immediately. While touring facility LPA observed construction. House Manager stated that construction workers were remodeling bathrooms. Facility did not let Community Care Licensing know of this remodeling. LPA requested new facility sketch since the remodeling would change their current facility sketch. House Manager stated that the construction would be done by next week. In the meantime, facility's plan is to keep residents safe by locking door that leads to construction during construction times and will not be accessible to residents in care. LPA requested updates of construction from facility and a written plan for the resident's safety during remodeling of bathroom. During walk through of backyard LPA observed an unlocked lock on the backyard gate. House Manager stated that facility locks the gate at night for safety. LPA stated that facility cannot lock any perimeter gates without an approved waiver from Community Care Licensing and approval from the Fire Department. A waiver has not been requested or submitted at this time. House Manager immediately removed lock and Administrator and House Manager understood the requirement and stated that facility will not lock any perimeter gates.

LPA requested the following documents:
Administrator Certificate, LIC 309, Plan for Incidental Medical and Dental Care, LIC 9020 and LIC610

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator, whose signature on this document confirms receipt. Report given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the facility did not comply with the section cited above in 1 out of 8 bedrooms had storage in room and 2 out of 5 restrooms also had supplies, laundry, toilet seat in tub, walker in tub and other supplies (photos taken) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/24/2021
	Plan of Correction
1 2 3 4	Facility will remove items from restrooms and shower and send LPA a photo when removed by 12/24/21.

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: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the facility did not comply with the section cited above in 1 out of 1 alcohol bottles were accessible to residents in care. LPA observed alcohol in refrigerator by resident rooms. Alcohol was unlocked and accesible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2021
	Plan of Correction
1 2 3 4	Facility agrees to keep all alcohol locked and inaccessible to residents in care. House Manager immediately removed alcohol and threw it away. Plan of correction corrected during 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: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6