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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 07/12/2021
Date Signed: 07/12/2021 05:12:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:RICASTA, JOCELYNFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 4DATE:
07/12/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jocelyn RicastaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Elliott conducted a case management- Legal/Non-compliance inspection, on 7/12/2021, at approximately 9:45 AM. LPA met with Administrator/Licensee Jocelyn Ricasata. This inspection is being completed to ensure compliance with Non-Compliance Conference dated 4/20/2021.

LPA noted staff present at facility were associated to facility. Upon arrival S1 greeted LPA without a mask. LPA was not screened and was told by Licensee they were giving resident a shower. LPA gave a copy of PIN 21-17 to Licensee. LPA observed visitor sign in sheet and temperature monitoring sheet. LPA observed cleaning supplies unsecured under the kitchen sink and medication cabinets unlocked, (Photos obtained). Licensee secured items. LPA also looked in backyard and observed open paint can, painting equipment, a box of construction screws, a leaf blower and discarded cardboard boxes, (Photo obtained) LPA toured resident rooms with Administrator. R1's room had a fridge with a locked box of insulin in the fridge, (Photos obtained). According to Administrator female staff draw up insulin with a syringe and clean the area on R1 where it is to be injected and R1 administers insulin and monitors blood glucose levels. (Photos obtained) LPA observed a plastic bottle of fabric softener with discarded syringes in the corner of R1's bedroom. (Photos obtained). LPA discussed that syringes need to be disposed of per regulation. LPA discussed that non-medical professional staff are not to draw up insulin. LPA provided Licensee with copy of regulations. LPA requested Licensee to contact R1's physician to have a discussion with primary care physician about having a medical professional come out or a pre-filled syringe for R1. LPA had a discussion that the issue needed to be resolved in 24 hours. LPA requested and received documentation for R1. While LPA was at facility Licensee obtained order for pre-filled pen for R1. LPA also obtained photos of R1's room as a follow-up to incident being monitored since 11/1/2020.


(See LIC - 809-C)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
VISIT DATE: 07/12/2021
NARRATIVE
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LPA reviewed received summaries for R2, R3, R4, R5, R6 on 4/30/2021. LPA requested documentation for R6. LPA noted events in summaries that were not reported to Community Care Licensing (CCL) for R2 on 12/20/2020 and R5 on 11/8/2021. Civil Penalty in the amount of $250.00 is being issued for repeat violation within the last 12 months. LPA requested additional documentation for R5 and R6. Additional time will be needed to continue this inspection.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.

(See LIC 809-D)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited

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87628 Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing...and is able to administer his/her own medication..administered orally or through injection...administered by an appropriately skilled professional.
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This requirement was not met as evidenced by: Based on LPA observation interview and record review, Licensee did not ensure medical professional staff are drawing up insulin. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Licensee agrees to submit a statement that licensee, and staff understand that only a skilled medical professional can perform glucose testing and draw/administer injectable medication when resident is unable to perform these tasks themselves by POC due date of 7/13/2021.
Type A
07/13/2021
Section Cited

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87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, ...gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review Licensee did not ensure toxins were secured. LPA observed medications, cleaning supplies and gardening and painting supplies unsecured. This poses an immediate risk to the health safety and personal rights of residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited

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87465(g )Incidental Medical and Dental Care Services. 9-1-1 shall be telephoned immediately if an injury or other circumstance ... This requirement is not met as evidenced by:
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Based on LPAs observation, interview and record review facility did not ensure R5 got medical attention when they sustained a head injury from a fall on 11/8/2020 and did not call 911. This poses an immediate risk to the health, safety and personal rights to residents in care.
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Type A
07/13/2021
Section Cited

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87468 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review Administrator/Licensee did not ensure S1 was wearing a mask and visitor screened as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited

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87303 Maintenance and Operation-(f) Solid waste shall be stored and disposed of as follows:(2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning blood borne pathogens. This requirement was not met as evidenced by:
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Licensee did not ensure syringes are disposed of in a bio hazard sharps waste container. LPA observed discarded syringes in a fabric softener bottle in R1's room. This poses a potential risk to the health, safety and personal rights of residents in care.
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Type B
07/26/2021
Section Cited

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87211 Reporting Requirements- (a) Each licensee shall furnish..(1) A written report shall be submitted…within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review incident reports were not sent to CCL within 7 days for R2 and R3. This poses a potential risk to the health, safety and personal rights to residents in care.
***Civil Penalty of $250.00 is being issued for repeat violation within the last 12 months.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5