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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803581
Report Date: 10/13/2023
Date Signed: 10/17/2023 12:03:30 PM


Document Has Been Signed on 10/17/2023 12:03 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:C&F SENIOR CARE HOME AMERICAN CANYONFACILITY NUMBER:
286803581
ADMINISTRATOR:FOJAS, LINAFACILITY TYPE:
740
ADDRESS:178 SONOMA CREEK WAYTELEPHONE:
(707) 246-0867
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:5CENSUS: 4DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Lina Fojas, AdministratorTIME COMPLETED:
04:34 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Lina Fojas. There are currently 4 residents in care. This facility is licensed for 5 non ambulatory residents, with hospice waiver approved for 4 of the residents and none of the residents are approved for bedridden.

LPA toured the home and found the home organized at a comfortable temperature with all exits free from obstruction. This home is a two level home and all the resident bedrooms are located on the first level of the home. Residents have a call button to alert staff for assistance. Exit doors have auditory alarms to alert staff. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the kitchen was observed charged and facility had a proof of purchase receipt attached of 6/19/2023. Fire drills are conducted and the last one was documented on 8/6/2023. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in locked cabinets in the kitchen.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. Residents' medications are stored in kitchen locked cabinet. Resident and staff files are located and locked in cabinet. LPA reviewed staff files and staff did not have proof of the required 8 hours of Dementia training. Staff had proof of 1st aid but did not have proof of at least 1 staff having CPR at all times. LPA also found staff S1 who was previously associated to this facility, was no longer associated, as the administrator sent in a request to Community Care Licensing (CCL) to remove S1 and S1 was removed by CCL on 8/7/2023. Administrator rehired S1 but failed to request a fingerprint association to associate S1 to this facility prior to working. Resident files were reviewed and found in compliance.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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: C&F SENIOR CARE HOME AMERICAN CANYON
FACILITY NUMBER: 286803581
VISIT DATE: 10/13/2023
NARRATIVE
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LPA discussed Emergency Disaster Plan and Infection Control Plan.

During todays visit, LPA requested facility to add lamps to all resident bedrooms.

Licensee/Administrator to submit the current following documents by 11/10/2023:


· LIC 308 Designation of Facility Responsibility (Received 10/13/2023)
· LIC 500 Personnel Report- (Received 10/13/2023)
· LIC 400 Affidavit Regarding Client/Resident Cash Resources(Received 10/13/2023)
· LIC 610E Emergency Disaster Plan(Received 10/13/2023)
· LIC 9020 Register of Facility Residents(Received 10/13/2023)
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance- (Received 10/13/2023)
Copy of Administrator Certificate

See report LIC809-D for Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided. Exit interview conducted with Lina Fojas.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/17/2023 12:03 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: C&F SENIOR CARE HOME AMERICAN CANYON
FACILITY NUMBER: 286803581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(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
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Based on todays inspection and record review with administrator, the licensee did not comply with the section cited above in staff present and/or providing night care do not have proof of having current CPR. all staff had First aid proof only and at least one present shall have proof of CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Facility agrees to ensure at least one staff present shall have proof of CPR. Facility to send proof of requirement to LPA A Canela by 11/2/2023
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection and record review, facility had rehired staff S1 and failed to re associate his fingerprints to this facility, after they had requested to remove S1 in August 2023. The licensee did not comply with the section cited above in 1 out of 3 staff reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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Facility to send in written plan to LPA A Canela on how they will ensure they are in compliance. Facility to request fingerprint association for staff S1 and send to LPA A Canela by 10/18/2023
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/17/2023 12:03 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: C&F SENIOR CARE HOME AMERICAN CANYON
FACILITY NUMBER: 286803581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(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
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Based on todays inspection and record review with administrator Lina Fojas, the licensee did not comply with the section cited above in 3 out of 3 staff, who did not have proof of 8 hours of Dementia training and facility cares for residents with dementia diagnosis, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Facility to send in proof all staff working in the facility have proof of required training at all times, as required. Facility to send in written statement with names of all staff who have completed training, date, type of training. POC due by 11/2/2023 to LPA A Canela.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4