286800667-12-18-2023-21-AS-SHAN-CYMVL5-20231218153118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 12/18/2023
Date Signed: 12/18/2023 03:31:48 PM

Document Has Been Signed on 12/18/2023 03:31 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:	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

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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff, Maria Sanchez. Viridiana Agapoff, Administrator was contacted by staff and arrived during the visit. There is a total of 7 residents, all with a diagnostic of dementia. There is 4 residents currently on Hospice. LPA toured the facility on 12/18/2023 at 9:00 AM; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility serves residents with dementia and has a plan of operation for special care and programming. All bedrooms have lighting & appropriate furnishings. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry area. Hot water temperature measured between 130.8 degrees F and 135.5 degrees F, falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 12/18/2023 at 9:30am. Administrator turned hot water heater down on the 1 (out of 2 hot water heaters at facility) regulating residents bathrooms (see LIC809-D). The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Fire Extinguisher was found to be last charged on 12/23/2022 at the time of the visit. Facility has fire sprinklers throughout. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. A review of 7 residents & 5 staff records as well as two resident’s medications was conducted during this visit. LPA reviewed resident’s files at 10:30 AM on 12/18/2023 and learned that 3 of 7 residents do not have an updated re-appraisals/needs & care plans and or updated physician’s assessments (LIC 602A) on file (see LIC809-D). Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

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 12/18/2023 03:31 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: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(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

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(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)

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 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.

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(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)

Care of Persons with Dementia

(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

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

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

NARRATIVE

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At approximately 12:00 PM LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Record review of 5 direct care staff files who were at work during inspection do not have proof of annual training requirements for 2023 on file (see LIC809-D). Administrator was unable to provide proof of First Aid & or CPR certification for staff that files were reviewed (see LIC809-D).

Medications were centrally stored in locked cabinet in the facility kitchen area & office. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 12/18/2023 at 1:30PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be completed and accurate.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Per Administrator disaster Drills are conducted annually with the last being 8/1/2023 & prior to that 9/15/22 (see LIC809-D). LPA advised they need to be conducted quarterly. Viridiana Agapoff, Administrator Certificate # 6061275740 expires on 8/8/2024.

Appeal of Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting facility to submit the following documents to CCL by 1/15/2024:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/18/2023 03:31 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: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

LIC809 (FAS) - (06/04)

Page: 10 of 12

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

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 26 27 28 29 30 31 32	LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Current Administrators Certificate Copy of Control of Property/New updated Lease Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
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

LIC809 (FAS) - (06/04)

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