Community Care Licensing

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Dina Alviso TELEPHONE: (707) 588-5082 LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023

FACILITY NAME: LINDA FALLS GUEST HOME 1	FACILITY NUMBER: 286802019
	VISIT DATE: 09/18/2023

FACILITY NAME: LINDA FALLS GUEST HOME 1	FACILITY NUMBER: 286802019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per file review and observations by the LPA, facility is fire cleared for four ambulatory, and two(2) non-ambulatory only. Licensee has a two additional non-ambulatory residents, and a bedridden resident admitted into the facility, which is out of compliance with the approved fire clearance, the licensee did not comply with the section cited above in [3] out of 3] admitted residents] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee tto ensure that admitted residents and residents retained are within the fireclearance approval; Licensee to submit updated facility sketch shwoing all resident rooms and current ambulatory/nonambulatory/bedridden status, submit an LIC200 if wanting to try and get a new fire clearance approval. If not able to obtain and/or you don't want to try to obtain a new fire clearance, please submit plan of how you will bring the facility into compliance. POC due 9/19/23.

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	Per record review, three out of four staff/caregivers lack current First Aid; Three out of four staff lack current CPR certification the licensee did not comply with the section cited above in [3] out of (4] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that all caregivers have first aid certification, and that staff obtain CPR certification, so on every shift the facility has at a minimum one staff that has CPR and their first aid. Copies od certifications by 9/23. Plan of correction due by 9/19/23.

SUPERVISOR'S NAME: Carla Martinez TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Dina Alviso TELEPHONE: (707) 588-5082 LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023

Document Has Been Signed on 09/18/2023 03:55 PM - It Cannot Be Edited

FACILITY NAME: LINDA FALLS GUEST HOME 1	FACILITY NUMBER: 286802019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2023

Type B

Section Cited

CCR

87625(b)(3)

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed a resident room to have a strong urine odor as soon as the resident's door was opened, the licensee did not comply with the section cited above in [1] out of [3] resident rooms] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that resident's room, R6, is cleaned and that the room is free from urine odors. Submit plan of correction by 9/29/23. Include how the correction was made and how facility plans on maintaing a clean urine free room for the resident. POC due 9/29/23.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation 87303(a) - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed that two resident rooms with very dirty carpet, one room is on the upstairs level, and the other is on the downstairs level, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that the resident room rugs are cleaned as needed. Submit photo of both the resident rooms rugs having been cleaned, and include how the facility will maintain the facility rug to be clean moving forward. POC due 9/29/23.

SUPERVISOR'S NAME: Carla Martinez TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Dina Alviso TELEPHONE: (707) 588-5082 LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023

Document Has Been Signed on 09/18/2023 03:55 PM - It Cannot Be Edited

FACILITY NAME: LINDA FALLS GUEST HOME 1	FACILITY NUMBER: 286802019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2023

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	Per record reviews, Three out of Four staff lack required annual training, the licensee did not comply with the section cited above in [3] out of [4] staff] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all staff obtain the annual required 20 hours of training. Submit copies of staff S2, S3, and S4's training having been completed by 10/29/23. POC due 10/29/23.

Section Cited

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

SUPERVISOR'S NAME: Carla Martinez TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Dina Alviso TELEPHONE: (707) 588-5082 LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023