286804062-6-2-2023-21-AS-VBEI-CSETCY-20230602143731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804062
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:37:38 PM

Document Has Been Signed on 06/02/2023 02:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	4K SENIOR HOME, LLC		FACILITY NUMBER:	286804062
ADMINISTRATOR:	HERNANDEZ, MARIA SOCORRO		FACILITY TYPE:	740
ADDRESS:	4147 MAHER STREET		TELEPHONE:	(707) 226-1293
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 6	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Maria Socorro Hernandez		TIME COMPLETED:	02:47 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Maria Socorro Hernandez arrived later. LPA initiated a tour of the facility around 11:40am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. One of six residents had a full bed rail on their bed, which is not allowable per regulation. Administrator indicated that the full bed rail is not used so LPA requested that it be removed. It was removed during this inspection. Water temperature in bathrooms used by residents measured at 120 and 129 degrees F which are not all within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Multiple cabinets in the bathroom were locked and after Administrator explained what items were in the cabinets LPA clarified that those items are not required to be locked, per regulation. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality but not all were stored per regulation. Pantry items were locked. LPA explained that if facility wanted to lock food, they would need to request a waiver from the Department. Facility opted to remove locks during inspection.. Medications were centrally stored and locked. Fire extinguisher was last serviced April 2023. Facility has hardwired smoke detectors located throughout the facility as well as a Carbon Monoxide detectors that were tested and operational during inspection. Most recent fire/disaster drill was conducted 3/2023. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 06/02/2023 02:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: 4K SENIOR HOME, LLC	FACILITY NUMBER: 286804062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the water higher than the range allowed per regulation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2023
	Plan of Correction
1 2 3 4	Staff immediately turned down water heater. Administrator agrees to continue to monitor water and submit a picture showing water within regulation to CCL no later than 6/3/2023.

Section Cited


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

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: 4K SENIOR HOME, LLC	FACILITY NUMBER: 286804062
	VISIT DATE: 06/02/2023

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Continued from LIC809

Four staff files and six resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Maria Socorro Hernandez 6014614740 expires 4/28/2024. Medications and medication records were reviewed.

Licensee/Administrator to submit updates of the following documents by 7/02/2023:
LIC 500 Personnel Summary
LIC 308 Designation of Responsibility
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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