286800667-1-29-2025-21-AS-JFLO-DDDSJM-20250129125521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 01/29/2025
Date Signed: 01/29/2025 12:55:32 PM

Document Has Been Signed on 01/29/2025 12:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CEDARS CARE HOME, THE		FACILITY NUMBER:	286800667
ADMINISTRATOR/ DIRECTOR:	VIRIDIANA AGAPOFF		FACILITY TYPE:	740
ADDRESS:	1520 CEDAR STREET		TELEPHONE:	(707) 942-9200
CITY:	CALISTOGA	STATE: CA	ZIP CODE:	94515
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 0	CENSUS: 8	DATE:	01/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Viridiana Agapoff, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:10 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	At approximately 9:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and were greeted by Viridiana Agapoff, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with eight (8) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for four (4), with four (4) Hospice residents currently in care, and is approved for all non-ambulatory residents. At approximately 10:30 AM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed two locked sheds in the backyard which LPAs inspected and observed the contents of one to consist of furniture, resident care equipment, and holiday decorations, and the other contains a water tank which is not currently being used. LPAs observed a piano, book shelves full of books, puzzles, crafting supplies and LPAs were informed that the facility plays bingo, watches movies, conduct afternoon exercises regularly, and has someone come play live music every Wednesday and Friday. Facility has an internet access device designated for resident use and internet service available. Facility telephone was tested an operational during inspection. Continued on LIC809-C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
	VISIT DATE: 01/29/2025

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Continued from LIC809C...

Facility has five (5) fire extinguishers which were observed charged and last serviced 01/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 12/2024. LPAs observed the facility's infection control plan, first aid kit, PPE, flashlights, and emergency supplies. Administrator states facility has a generator for emergency preparedness. LPAs reviewed facility's emergency disaster plan last updated 12/2024.

Administrator states that the residents families coordinate residents' medical and dental appointments and transportation to and from visits. However, Administrator also states that facility will assist with coordinating these appointments and transportation for residents upon request. However, residents need to pay for this subcontracted transportation service. Facility does not manage P&I.

Administrator had a family emergency. LPAs will return at a later date to complete the annual inspection. LPAs will review resident files, staff files, and medications and medication logs during that visit.

No deficiencies were cited during inspection.

Exit interview conducted with Administrator whose signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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