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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480107184
Report Date: 04/08/2022
Date Signed: 04/08/2022 05:55:09 PM

Document Has Been Signed on 04/08/2022 05:55 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:DELTA MEADOWS CARE HOMEFACILITY NUMBER:
480107184
ADMINISTRATOR:CECILIA GANZONFACILITY TYPE:
740
ADDRESS:101 O'BRIEN CIRCLETELEPHONE:
(707) 647-1759
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Cecilia GanzonTIME COMPLETED:
01:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Cecilia Ganzon. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. The facility currently has 4 residents in care. This facility is licensed for a total of 5 residents. 3 bedrooms may be used for non-ambulatory residents and bedroom #1 may only be used for ambulatory residents. This facility has a Hospice waiver approved for 2 residents and does not have approval for bedridden residents.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices that are present are: entry procedures, face coverings and 30-day PPE supply. Facility does not have proof of daily monitoring and temperatures checked for residents and staff. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department on 8/20/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged and serviced 11/29/2021. Facility has 2 resident room doors that are getting stuck and will need to be corrected for easy opening and closing.

Continue report see LIC809-C and LIC809-D for citations issued during todays inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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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: DELTA MEADOWS CARE HOME
FACILITY NUMBER: 480107184
VISIT DATE: 04/08/2022
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During todays visit, LPA discovered resident R1 was hospitalized from 2/10-2/13/2022, was also sent to the ER on other occasions, and the Vallejo police department made a health & safety check to this facility on 1-2 occasions and facility failed to notify CCL and submit the required incident reports within 7 days. Facility staff to get N95 fit tested.

Exit interview conducted with Cecilia Ganzon

See LIC809-D for citations issued
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights and report emailed to facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2022 05:55 PM - It Cannot Be Edited


Created By: Araceli Canela On 04/08/2022 at 12:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DELTA MEADOWS CARE HOME
FACILITY NUMBER: 480107184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Canelas observation during todays inspection tour of the facility, the licensee did not comply with the section cited above in 2 out of 2 sliding doors. LPA and Administrator Cecilia observed, the doors are not opening and closing easily, in addition 1of 2 doors needs a proper door handle, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Facility called maintenance personnel to correct sliding door problem. Facility to send in written plan on how facility will ensure all doors open properly and proof of correction by
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs interview with staff S1 and records reviewed. It was disclosed the Vallejo police department conducted 1-2 Safety checks on facility, resident R1 was sent to the hospital on more than1 occasion and hospital records show R1 was hospitalized in February 2022 and facility failed to report and send in an incident report to CCL within the required time. The licensee did not comply with the section cited above in 2-4 incidents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Facility to send in written plan they understand reporting requirements, how the facility will ensure requirements are met within the required time, proof staff understand and have been trained and submit incident repots that were not submitted by POC due date 4/13/2022 to LPA A Canela
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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
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