Community Care Licensing

Document Has Been Signed on 12/18/2023 03:31 PM - It Cannot Be Edited

FACILITY NAME:	CEDARS CARE HOME, THE		FACILITY NUMBER:	286800667
ADMINISTRATOR:	VIRIDIANA AGAPOFF		FACILITY TYPE:	740
ADDRESS:	1520 CEDAR STREET		TELEPHONE:	(707) 942-9200
CITY:	CALISTOGA	STATE: CA	ZIP CODE:	94515
CAPACITY: 12		CENSUS: 7	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Viridiana Agapoff, Administrator		TIME COMPLETED:	03:45 PM

SUPERVISORS NAME: Bethany Moellers LICENSING EVALUATOR NAME: Shannan Hansen LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023

Link to Parent Document Below:

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

Type A

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Administrator and record review the facility neglected to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses an immediate health, safety risk to residents in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that at least one staff on duty has CPR training at all times and all staff have current 1st Aid training. Licensee to submit LIC 9098 self certification that staff have been CPR trained per regulation and that facility will maintain a staff on duty who has CPR training at all times by POC due date 12/19/2023 & to provide copies of all 5 (S1-S5) certificates by 12/29/2023 to clear citation.

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 3 residents bathroom water faucets measured 130.8 degrees F & 135.5 degrees F, which are not within the allowable ranges of 105 to 120 degrees F. which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	Administrator lowered 1 of 2 hot water heaters during visit. Administrator to submit document stating they understand the regulation by 12/19/2023 with pic of proof of decreased water temp & Administrator will also submit as proof of correction a week measurement log of water temperature readings, taken once in the morning and once at night, showing temperatures in compliance with regulation 87303(e)(2), 2nd poc date Dec .25, 2023

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Shannan Hansen LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023

Link to Parent Document Below:

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

Type B

Section Cited

HSC

1569.625(b)(2)

(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 LPA's observation & record review, the licensee did not comply with the section cited above in 5 out of 5 staff (S1-S5) did not have current/updated required trainings (any for 2023) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to ensure training requirements are met. Administrator agrees to submit proof of required trainings for S1-S5 to LPA by POC due date of 1/5/2024

Type B

Section Cited

CCR

87463(c)

(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 LPA's interview with Administrator and record review, the licensee did not comply with the section cited above in 3 out of 7 residents (R1, R2, & R3) did not have current updated reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator to submit updated Reappraisals for R1, R2, & R3 by POC due date of 1/5/2024 to Clear citation with a statement of how this will be prevented going forward for residents.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Shannan Hansen LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023

Link to Parent Document Below:

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews conducted with Administrator, the facility did not comply with the section cited above per regulation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to submit written plan, outlining how facility will conduct required drills per regulation. Licensee will also conduct a drill and submit written evidence of completed drill to CCL by POC date of 01/05/2024.

Type B

Section Cited

CCR

87705(c)(3)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Administrator &record review, the licensee did not comply with the section cited above in 5 out of 5 staff (S1-S5) did not have required training in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator to ensure training requirements are met. Administrator agrees to submit proof of required trainings for S1-S5 to LPA by POC due date of 1/5/2024

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Shannan Hansen LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
	VISIT DATE: 12/18/2023

Link to Parent Document Below:

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

Type B

Section Cited

CCR

87705(c)(5)

87705(c)(5) Care of Persons with Dementia- Each resident with dementia shall have an annual medical assessment& reappraisal done at least annually... Ths requirement isnt met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 7 residents (R1-R3) did not have current, updated medical assessments (602)'s which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to ensure medical assessments are done, review and update to ensure all resident's needs are met. Licensee to submit a LIC 9098 self certification that facility has acquired LIC 602s medical assessment for residents R1, R2, R3, on file to be reviewed by the Department to CCL by POC date of 01/05/2024.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Shannan Hansen LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
	VISIT DATE: 12/18/2023