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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002868
Report Date: 05/02/2022
Date Signed: 05/03/2022 07:40:28 AM


Document Has Been Signed on 05/03/2022 07:40 AM - 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:HAZEL HOME FOR SENIORSFACILITY NUMBER:
345002868
ADMINISTRATOR:GRANT, CLEOPATRAFACILITY TYPE:
740
ADDRESS:4919 HAZEL AVENUETELEPHONE:
(831) 334-1223
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
05/02/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Cleopatra "Cleo" GrantTIME COMPLETED:
07:00 PM
NARRATIVE
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On today's date around 905 am Licensing Program Analysst (LPAs) Kevin Mknelly and Mai Thao arrived at the facility unannounced to conduct a Post Licensing Inspection utilizing the CARE tool. LPA met with Cleo, Administrator. LPA explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. In addition, Staff screened LPA prior to entering the facility.

LPA toured facility with staff to ensure health and safety of clients in care. Areas toured include but are not limited to: common area, 2 bathroom, 4 client bedroom, 1 staff bedroom, laundry room, garage, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed.
LPAs reviewed resident, staff and facility records and conducted a medication audit. LPA and staff completed the infection control domain.

Several deficiencies were noted as citations and technical violations.

During the inspection, LPA and facility staff discussed the facility's infection control and mitigation plan, training requirements, staff and resident records, facility and medication quality assurances.
Report continued...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
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 05/03/2022 07:40 AM - 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: HAZEL HOME FOR SENIORS
FACILITY NUMBER: 345002868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 chemicals unsecured in the kitchen and bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Disinfectants secured while LPAs present

Licensee will submit a plan to ensure monitoring of facility safety
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in two of three caregvers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee will submit proof of S2 and S3 initial 20 hours, 1st and and restricted conditions training by 5/6/22

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: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2022 07:40 AM - 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: HAZEL HOME FOR SENIORS
FACILITY NUMBER: 345002868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 staff files S1 S2 and S3 did not have proof of medication training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee will provide proof of required medication training by the plan of correction (POC) date of 5/6/22
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 of 4 resuidents R2 R3 and R4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licnese will update appraisal/ needs and services plans for all residents who have significant changes of condition and establish review meeting dates by the POC date of 5/30/22.

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: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2022 07:40 AM - 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: HAZEL HOME FOR SENIORS
FACILITY NUMBER: 345002868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 of 3 residents who receive PRN medications do not have PRN authorization letters on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee will submit proof of letters signed by physician for residents receiving PRN medication by the POC date of 5/30/22
Type B
Section Cited
CCR
87212(b)(1)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 of 3 caregivers do not have documented knowledge of nor designation to be a responsible party in the Administrator's absence which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2022
Plan of Correction
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Licensee will submit LIC 308s for those staff to be responsible and are trained to CCL by the POC date of 5/16/22

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: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 05/03/2022 07:40 AM - 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: HAZEL HOME FOR SENIORS
FACILITY NUMBER: 345002868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(5)
Oxygen Administration - Gas and Liquid
(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatioj and records review the licensee did not comply with the section cited above in1 of 1 residents with Oxygen does not have a plan and staff training in place to assist R1 as needed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2022
Plan of Correction
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Licensee will submit proof of training and the restricted health condition plan to CCL by the POC date of 5/16/22
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 of 3 staff, S2 S3 do not have record of dementia training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee will sumit proof of training to CCL by the POC date of 5/6/22.

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: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


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: HAZEL HOME FOR SENIORS
FACILITY NUMBER: 345002868
VISIT DATE: 05/02/2022
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As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Cleo .

Due to technical issues LPA was unable to leave a copy of the report with the administrator. Copy of this report and appeal rights provided via email with request for the licensee to return signed copies.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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