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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802019
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:52:00 PM


Document Has Been Signed on 11/07/2023 02:52 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:LINDA FALLS GUEST HOME 1FACILITY NUMBER:
286802019
ADMINISTRATOR:SACRO, NORBERTFACILITY TYPE:
740
ADDRESS:755 LINDA FALLS TERRACETELEPHONE:
(707) 963-1440
CITY:ANGWINSTATE: CAZIP CODE:
94508
CAPACITY:6CENSUS: 6DATE:
11/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Rosita O'Campo-Lead CaregiverTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management visit, on 11/7/23 at approximately 11:23am, and met with Rosita O'Campo, Lead Caregiver. LPA observed another caregiver, Zenaida Narciso, on duty during the inspection.

LPA observed a large container of several prescribed medications, as well as over the counter medications out in the open, not locked up, stored in the corner right side of the common area on the lower level. LPA obtained pictures. This deficiency will be cited, 87465(h)(2) Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.

LPA observed there are three (3) residents on the upper level, two (2) residents have/use walkers, and one (1) resident is wheelchair bound. LPA observed the inside upper-level stairway entry is open and accessible to residents who are non-ambulatory, there is no barrier for residents’ safety, this is a health and safety hazard to residents in care. LPA observed that the upper-level sliding door leads out to a balcony which at the end of the balcony are steep stairs with no barrier for residents safety, this is a health and safety hazard, deficiency will be cited, Personal Accommodations and Services (d)(4)-The following space and safety provisions shall apply to all facilities: Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents, see LIC809D.

LPA observed the facility does not have fire/emergency exits per LPA's inspection, the facility only has stairs inside on the upper floor and outside stairs from the balcony, this is a health and safety hazard to residents in care. This deficiency will be cited, H&S Code Emergency Plans 1569.695 (a)(d) (1)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. An evacuation chair at each stairwell, see LIC809D.

Licensee to ensure that all deficiencies are corrected in a timely manner, and all plans of corrections are submitted by due dates, see LIC809Ds.


Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019
VISIT DATE: 11/07/2023
NARRATIVE
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The Department has contacted the State Fire Department, Fire Department for outside of Napa city limits, regarding information on fire clearance approval; The Department requested information from State Fire Department on fire code requirements for non-ambulatory on a second floor, and required emergency fire exits on a second floor.

Emergency and disaster plan, LIC610E, must be reviewed, updated, signed/dated, and submitted to the licensing Department, regarding current residents in care and facility emergency evacuations, including facility having evacuation chairs. This plan is due no later than 11/17/23.

All staff must be trained in the updated emergency disaster plan; Staff to be trained in instructions on use of the evacuation chair, ensure staff know how to operate it. Staff are to be trained in the facility policy and procedures, regarding the two sturdy barrier gates. Licensee agreed to install the barrier gates, one at the top of the inside stairs, and one outside at the top of the balcony. Proof of training due by 11/30/23. Include trainer, topics, date/time spent, and attendees.

Licensee has agreed to ensure secure sturdy barriers/gates are installed, one inside the facility at the top of the stairs on the second level, and on the outside second level balcony at the top of the stairs.. All staff are to be trained in the policy and use, 24/7, of the gates being kept closed at all times. This must be installed and completed no later than 11/30/23.

Licensee has agreed to submit a plan on ensuring sufficient staffing to supervise residents at all times in regard to the stairs inside the facility and the stairs outside off the balcony that currently don't have barriers for residents safety. You will ensure all residents are supervised as needed, 24/7, to ensure health and safety regarding these stair openings, until both the stairs have barriers as required. Residents have the right to access the facility common areas, the Licensee is to ensure sufficient staffing as to not restrict residents' use of the common areas. Please submit this plan including the above no later than 11/9/23.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D pages.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Exit interview conducted with the Administrator Norbert Sacro.
Appeal Rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/07/2023 02:52 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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2023
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met, as evidenced by:
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Administrator to ensure all medications are centrally stored and inaccessible to residents in care. Administrator to hold an in-service regarding facility's medication policy and procedures regarding storage of medications. Follow-up proof of training to be submitted by 11/14/23.
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LPA observed a large container of several prescribed medications, as well as over the counter medications, of R1, out in the open, not locked up, This is an immediate health and safety risk to residents in care.
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POC due 11/8/23.
Type A
11/08/2023
Section Cited
CCR87307(d)(4)

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87307 Personal Accommodations and Services (d)(4)-The following space and safety provisions shall apply to all facilities: Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents.This requirement was not met, as evidenced by:
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Licensee has agreed to install barrier gates, one at the top of the facility upper level inside stairs, and at the top of the stairs off the upper level outside balcony. Plan on getting the barrier gates installed for residents' safety inside and outside of the facility common areas. Submit completion notification to the Department of installed gates no later than 11/20/23.
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LPA observed there are three (3) residents on the upper level, two (2) residents have/use walkers, and one (1) resident is wheelchair bound. LPA observed the inside upper-level stairs has no barrier, and the upper-level outside balcony stairs has no barrier, this is a health and safety risk to residents in care
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Submit plan of correction by 11/8/23.
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/07/2023 02:52 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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2023
Section Cited
HSC
1569.695(a)(d)(1)

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Emergency Plans 1569.695 (a)(d) (1)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. An evacuation chair at each stairwell. This requirement was not met as evidenced by:
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Licensee to ensure that the facility has evacuation chairs to assist in evacuating residents in the vent of an emergency at either the stairs inside the facility on the upper level, and/or the stairs off the balcony on the upper level. Both the stair areas, inside and outside, are the only ways out of the facility's second floor.
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LPA observed three non-ambulatory residents on the upper level. LPA observed the facility does not have fire/emergency exits per LPA's inspection, the facility only has stairs inside on the upper floor and outside stairs from the balcony, this is a health and safety risk to residents in care.
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Licensee to submit copy of receipt of purchase of evacuation chairs, and pictures of the evacuation chairs for the facility. POC due 11/10/23.
Reminder-Post up the evacuation chair use instructions where the evac chairs are kept. by stair areas.

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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4