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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700777
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:35:27 PM


Document Has Been Signed on 06/09/2022 01:35 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SIGNATURE LIVING ON WINDING WAY IIFACILITY NUMBER:
342700777
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6270 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Scott AffableTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kevin Mknelly and Cassie Yang arrived at the facility unannounced on 6/9/22 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. Deficiencies noted included: Pool fence found unlocked at 11:55 AM, house hold chemicals found unsecured and fire door was held by a door stop.
LPA and Admin completed the infection control domain. Home is in significant compliance.
LPAs advised: recording resident and staff daily symptom screening, hand washing signs in bathroom, trash cans have no touch lids, emergency plan be reviewed annually.

LPA requested the following records: Resident roster, staff roster lic 500, proof of insurance and LIC 308 (for designees if applicable), liability Ins and last page of Ener Plan.
As a result of this visit, see attached deficiencies . Exit interview conducted and copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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 5


Document Has Been Signed on 06/09/2022 01:35 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: SIGNATURE LIVING ON WINDING WAY II
FACILITY NUMBER: 342700777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPAs and caregiver found the pool gate unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2022
Plan of Correction
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Pool was lockd while LPAs were present .
Licensee will submit proof of policy to ensure pool is locked after service and reviewed by all staff by the POC date of 6/16/22
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 06/09/2022 01:35 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: SIGNATURE LIVING ON WINDING WAY II
FACILITY NUMBER: 342700777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above in that unsecured cleaning supplies were found at a hall closet and in a basket by the washerwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2022
Plan of Correction
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Items were secured while LPAs were resent.

Licensee will submit a plan that is reviewed with all staff to ensure chemicals are sucured safely from residednts by the POC date of 6/16/22.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5