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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803969
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:24:28 PM


Document Has Been Signed on 04/23/2024 02:24 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:ANNIE'S FAMILY HOME CARE OF CALISTOGAFACILITY NUMBER:
286803969
ADMINISTRATOR:CARISMA PATTERSONFACILITY TYPE:
740
ADDRESS:1119 MITZI DR.TELEPHONE:
(707) 326-1994
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:6CENSUS: 3DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Carisma PattersonTIME COMPLETED:
02:30 PM
NARRATIVE
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On April 23, 2024, Licensing Program Analyst (LPA) Shannan Hansen made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator Carisma Patterson. Facility has 3 residents, all on hospice.

At approximately 8:45 AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area although Administrator was informed a copy of facility Admissions Agreement is to be posted in public view per Regulation 87507( e)(2) (see LIC9102). The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage cupboard. Water temperature measured 119.4 degrees F and 133.8 degrees F., falling out of regulations between 105 and 120 degrees F in 1 out of 2 faucets accessible to residents (see LIC809-D). Administrator adjusted water heater during visit. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguishers were last inspected 5/9/2023. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present and also in working order. There was enough lighting in all common areas, resident rooms, and hallways. LPA observed activity supplies, puzzles, and newspapers for resident use. Medication is centrally stored and secure in individually locked cabinets in garage.

At approximately 10:00 AM, LPA reviewed 3 of 3 resident records and found 3 of 3 residents have current physician’s reports although 3 of 3 residents did contain required updated Reappraisals/care plans indicating change of conditions (see LIC809-D). 3 of 3 resident records contained current and signed admission agreements.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2024 02:24 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: ANNIE'S FAMILY HOME CARE OF CALISTOGA
FACILITY NUMBER: 286803969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit, the licensee did not comply w/section cited above in 3 out of 3 residents medication records which poses/a potential health, safety or personal rights risk to persons in care. LPA learned that facility has not maintained CSMR for 3 out of 3 residents.
POC Due Date: 05/10/2024
Plan of Correction
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Licensee to ensure that all residents' medications are entered on a Centrally Stored Medication Record. Facility to provide CCL with copies of CSMR for all residents' medications by the POC due date of 5/10/2024
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview and record review, facility did not comply with the section cited above in 3 out of 3 residents' reappraisals which poses a potential health, safety or personal rights risk to persons in care.Dept learned that all 3 current residents do not have reappraisal or they are over 12 months.
POC Due Date: 05/10/2024
Plan of Correction
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Facility to ensure that reappraisals are conducted at least every 12 months and/or any time there is a change of condition. Facility review residents careplans and provide Department with a self certification as proof that all careplans/reappraisals have been updated, reviewed & resident and/or responsible party by POC due date of 5/10/2024.
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: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2024 02:24 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: ANNIE'S FAMILY HOME CARE OF CALISTOGA
FACILITY NUMBER: 286803969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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Based on interview, and record review the licensee did not comply w/section cited above in 1 of 1 facility drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Facility to ensure that facility will conduct quarterly disaster drills as required by Health & Safety Code. Licensee to submit to CCL proof of disaster drill conducted and copy of loggings maintining drills by POC date of 5/10/2024
Type B
Section Cited
CCR
87303(e)(2)

87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's & Administrators observation, the licensee did not comply with the section cited above in 1 out of 2 faucets supplying water to residents in care tested at 133.8 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator adjusted water heater during visit but was still not within regulations.
POC Due Date: 05/10/2024
Plan of Correction
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Facility to submit a 10 day log checking water twice a day by POC due date of 5/10/2024 in order to clear this citation. Note: During visit LPA observed Administrator adjusted the water heater temperature.
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: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


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: ANNIE'S FAMILY HOME CARE OF CALISTOGA
FACILITY NUMBER: 286803969
VISIT DATE: 04/23/2024
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At approximately 11:20 AM, LPA reviewed 4 of 4 staff records. 4 of 4 records contain documentation of completed training records as required. Evidence of current first aid and CPR training were observed.

Medications were centrally stored in locked cabinet in the facility laundry/lounge room. At approximately 1:15pm LPA observed facility has not kept a log of Centrally Stored Medication Record (CSMR) (see LIC809-D)



Facility has a generator to supply power during an outage. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility records indicate they conduct quarterly disaster drills with the last disaster drill conducted on 3/10/2023. Administrator informed they changed over to logging in licensee’s laptop after 3/10/2023 and that is not available at this time (see LIC809-D). Carisma Patterson Administrator Certificate 6060960740 expired 10/27/2023 LPA was presented proof of trainings & Certificate submission. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; no need to change any of the information other then facility number to change with mobile.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 5/10/2024:



LIC 308 Designation of Responsibility (if changed)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility /Resident’s
Control of Property – Deed
Copy of Administrator’s Certificate
Proof of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7