286804071-10-23-2023-21-AS-DALO-CWVUF7-20231023153215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804071
Report Date: 10/23/2023
Date Signed: 10/23/2023 03:32:21 PM

Document Has Been Signed on 10/23/2023 03:32 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:	GOLDEN HEARTS SENIOR CARE, LLC		FACILITY NUMBER:	286804071
ADMINISTRATOR:	MANALO, EDWARDSON		FACILITY TYPE:	740
ADDRESS:	1630 ARCADIA COURT		TELEPHONE:	(415) 770-4285
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 4	DATE:	10/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Edwardson Manalo-Administrator		TIME COMPLETED:	03:40 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) Alviso, conduct a Required- 1 Year inspection and met with Administrator Edwardson Manalo. There are currently two (2) residents on hospice care. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved hospice waiver for residents in care as needed. There is an approved plan of dementia care. Fire clearance is approved for six (6) non-ambulatory. The LPA reviewed four (4) client files. The LPA reviewed six (6) staff files. All staff had criminal record clearance as required. LPA toured the facility with Administrator. Hot water was checked 112.8 Fahrenheit. LPA observed all exits to be free of obstructions. Fire extinguisher is tagged and serviced as required. Napa Fire Department came out and inspected the fire alarm system, passed inspection, 8/8/2023. Facility's smoke alarms are also carbon monoxide detector; There are also two separate smoke alarms. Food supply was observed to be sufficient. The facility was clean and orderly. Facility had a sufficient supply of hygiene products, cleaners, and paper products. Facility had a sufficient supply of personal protective equipment (PPE). Bathrooms had roll in showers, grab bars, and mats for resident use. Facility had night lights for resident use as needed. LPA observed a 72 hour shelter in place supply, which is required. Licensee/Administrator to submit the following documents by 11/23/23: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 9020 Register of Residents LIC 610 E Emergency Disaster Plan for RCFE -reviewed & updated as needed Copy of current Liability Insurance Infection Control Plan-reviewed & updated as needed LIC400 Handling of Client Cash Resources, include copy of surety bond. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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 10/23/2023 03:32 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: GOLDEN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 286804071
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2023

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
1 2 3 4	Based on LPA's file review, there were no documented records of facility's quarterly emergency drills, the licensee did not comply with the section cited above in quarterly emergency drill requirements which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that quarterly emergency drills are conducted and documented as required. Submit plan on how the facility will conduct an emergecny drill, document it, and ensure facility maintains compliance with the above. POC due 10/30/23.

Type B

Section Cited

CCR

87411(f)

87411 (f) Personnel Requirements - General-all personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's file review, Three (3) out of five (5) staff (S1, S2, S3) did not have a completed health screening report, including a TB test and results, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all staff complete the LIC503 Health Screening Report, including TB test & results. Submit copies of staffs completed forms by POC due date 10/30/23.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 286804071
	VISIT DATE: 10/23/2023

NARRATIVE

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The following deficiencies were cited:
Based on LPA's file review, there were no documented records of facility's quarterly emergency drills. This will be cited, H&S Code 1569.695 ( c) a facility shall conduct a drill at least quarterly for each shift. 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, see LIC809D.

Based on LPA's file review, Three (3) out of five (5) staff did not have a completed health screening report, including a TB test and results.This deficiency will be cited, 87411 (f) Personnel Requirements - General-all personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure, see LIC809D.

Based on LPA’s file review, S1 didn’t have an annual medical assessment which is required, this will be cited, Care of Persons with Dementia 87705 (c ) (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs, see LIC809D.

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.

Exit interview conducted with the Licensee/Administrator Edwardson Manalo.
Appeal rights provided to the Administrator Edwardson Manalo.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/23/2023 03:32 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: GOLDEN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 286804071
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 (c ) (5) Care of Persons with Dementia Licensees who accept and retain residents with dementia shall be- responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA’s file review, S1 didn’t have an annual medical assessment which is required, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that S1 obtains a medical assessment by 11/15/23; Submit a copy of the residents medical assessment by POC due date of 11/15/23.

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: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC809 (FAS) - (06/04)

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