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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700763
Report Date: 02/07/2022
Date Signed: 02/07/2022 05:45:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:A-1 ELDERLY CAREFACILITY NUMBER:
342700763
ADMINISTRATOR:TIF, ROBERTFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVETELEPHONE:
(916) 996-4763
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Robert Tif, AdministratorTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA spoke with Desrene Hall, caregiver, and observed her to be wearing a mask. Caregiver contacted Robert Tif, Administrator by phone, who arrived shortly to the facility. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering. The following Personal Protective Equipment (PPE) was worn: N95 Mask. LPA observed (2) residents watching television in the common area and (2) residents resting in their rooms. No residents are currently receiving hospice services.

LPA and caregiver toured and observed the facility to ensure the health and safety of residents in care. Areas toured include: common areas, (2) private bedrooms, (2) shared bedrooms, (2) resident bathrooms, (2) vacant private rooms, (1) staff/break room, dining room, laundry area and kitchen. LPA observed 2+day perishable and 7+day non-perishable food supply and PPE supplies for 30+days on hand. LPA observed locked toxins, medications and sharps. In the areas toured, there were no immediate health, safety, or personal rights violations observed. LPA and Administrator completed the infection control domain. Inside temperature was observed to be 73* F. LPA observed several Covid posters posted at/near the front entrance and in the bathrooms -LPA to provide additional posters to post throughout. LPA observed other required postings in place. Administrator Certificate #6047124740 posted (exp 2/9/2022)- Administrator showed proof of mailing receipt for renewal. Fire extinguisher last serviced 7/14/2021. Administrator to check his records if a mitigation plan was submitted and has not approved yet- will submit by Friday, 2/11/2022.
Liability insurance was not renewed prior to expiration. Discussed vaccination status of residents and staff as well as PIN 22-04 issued 1/18/2022 regarding current testing and visitation requirements. LPA requested completed LIC308 be emailed to the Department by 2/11/22.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: A-1 ELDERLY CARE
FACILITY NUMBER: 342700763
VISIT DATE: 02/07/2022
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Per California Code of Regulations, Title 22, Chapter 8, Division 6, the following (2) deficiencies were issued. See 809D for citations issued.

Exit interview.

Copy of report and appeal rights provided to Administrator at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A-1 ELDERLY CARE
FACILITY NUMBER: 342700763
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1 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, furnishings and equipment.

This requirement is not met as evidenced by:

Based on interview with Administrator and caregiver (S1), the Licensee did not ensure that the required Covid-19 protocols regarding staff testing for Covid-19 weekly and maintaining documentation of testing results and/or vaccination status (or exemption) on file, which poses a potential health and safety risk to residents in care.
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above in 4 out of 4 staff persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2022
Plan of Correction
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2
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Licensee/Administrator agree to obtain documentation from each staff person of vaccination status and/or a medical/religious exemption claimed and documentation that testing is conducted weekly per current Covid-19 precuationary measures in place. Administrator agrees to send documentation of the above to CCLD by 2/21/22. Testing needs to be conducted this week.
Type B
Section Cited
HSC
1569.605
H & S 1569.605 Liability insurance; coverage requirements.

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Per Licensee, she has not obtained the required Liability insurance for this facility.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Administrator, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2022
Plan of Correction
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The Licensee shall obtain required liability insurance for facility and submit proof of insurance to CCL by POC date, 2/21/2022
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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