Community Care Licensing

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 03:06 PM - It Cannot Be Edited

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type B

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, Licensee did not comply with the section cited above. Bathroom sink facuets were observed with the following temperatures of 120.7 degrees F & 123 degrees F. This poses an immediate health, safety, and personal risk to residents in care. LIcensee turned down water heater at time of visit.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Licensee to submit a self-certification stating they will do the following log: Facility to adjust temperature and submit a 10 day log checking water twice a day by POC due date of 11/10/2023 in order to clear this citation. Note: During visit LPA observed Administrator adjusted the water heater temperature.

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 record review, 2 of 2 staff on duty did not have the additional training hours on file S1 & S2, which poses a potential health, safety, personal risk to residents in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have staff complete training and send to CCL with form LIC9098 by POC due date 1/12/2024 to clear deficiency.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 03:06 PM - It Cannot Be Edited

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

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 observation and record review, the licensee did not comply with the section cited above in 4 out of 4 residents did not have Appraisals or Reappraisals conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee to review & or create all resident's care plans, update them accordingly and submit copies of all 4 residents careplans to CCL by POC due date to clear deficiency.

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, the licensee did not comply with the section cited above per regulation,in conducting quarterly disaster drills with staff in different shifts and document, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	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 01/12/2024

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 03:06 PM - It Cannot Be Edited

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type B

Section Cited

CCR

87705(f)(2)

(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	This requirement was not met, as evidenced by: During today's visit LPA found ,all cleaning detergents & toxins in unlocked garage cabinet while audio alarm to kitchen door was unoperational. This is an immediate risk to Health & Safety of residents in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Staff immediately locked garage cabinet and adjusted audio alarm to door. Facility to send in written plan they understand regulation and how it will be followed. Facility removed items that should not be accessible and will conduct and send proof of staff training. POC due date 1/5/2024

Type B

Section Cited

CCR

87412(g)(1)

87412 Personnel Records (g) All personnel records shall be maintained at the facility & shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above not having records available for Licensing to review during visit including updated personnel report which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit self certification that all resident/staff files are accessible for review and contain all required documents by POC due date.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
	VISIT DATE: 01/04/2024

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type B

Section Cited

CCR

87457(c)(1)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and record review, the licensee did not comply with the section cited above in 4 out of 4 residents files did not contain required pre-Admission Apprails which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee agrees to ensure prior to admission resident appraisals are completed. Licensee agrees to complete resident appraisals for R1, R2, R3, R4 with responsible parties to determine appropriateness of residents being at facility and send a copy to LPA by POC due date of 1/12/2024.

Type B

Section Cited

CCR

87705(c)(6)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	** Based on resident's files review the licensee didn't comply w/section cited above in 4 out 4 residents which poses a potential healty risk to person in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee to ensure reappraisals are done, review and update to ensure all resident's needs are met. Licensee to submit a LIC 9098 self certification that facility care plans for R1,R2, R3, & R4 are on file to be reviewed by the Department to CCL by POC date of 1/12/2023.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 03:06 PM - It Cannot Be Edited

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type A

Section Cited

CCR

87705(f)(1)

87705(f)(1) (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed knives and other sharp objects in an unlocked drawer in the kitchen accessible to residents in care. This poses an immediate 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 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 1/5/2024, and Training to be submitted by due date of 1/12/2024.

Section Cited

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

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 03:06 PM - It Cannot Be Edited

FACILITY NAME: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type B

Section Cited

CCR

87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of record review and interview with staff and LIcensee, the licensee did not comply with the section cited above in 1out of 1 staff did not have proof of current 1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 1/12/2024.

Section Cited

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

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5026 LICENSING EVALUATOR NAME: Shannan Hansen TELEPHONE: 707-588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024