480107184-2-10-2023-21-AS-DTOA-CNWSQB-20230210130429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 480107184
Report Date: 02/10/2023
Date Signed: 02/10/2023 01:04:38 PM

Document Has Been Signed on 02/10/2023 01:04 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 HOME		FACILITY NUMBER:	480107184
ADMINISTRATOR:	CECILIA GANZON		FACILITY TYPE:	740
ADDRESS:	101 O'BRIEN CIRCLE		TELEPHONE:	(707) 647-1759
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	5	CENSUS: 4	DATE:	02/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:44 AM
MET WITH:	Cecilia Ganzon, Licensee		TIME COMPLETED:	01:15 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	On 2/10/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Lead Staff Janet Cancino. Licensee, Cecilia Ganzon was contacted and arrived later in the visit. The facility currently provides care for 4 residents all of which were present at the time of visit, none of which are receiving hospice services and some of which with a of diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/26/2022 at the time of the visit. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be participating in their individual activities including watching television, conversing or with visitors. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens. There was a supply of hygiene products and paper products available for resident use. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file. Toxins are stored in a locked cabinet in the facility garage and found to be secured. LPA observed prescription medications unsecured in the office area. LPA was informed that the medications were in process of being recorded and put away. No residents were present. LPA discussed with Licensee and staff and issued Technical Violation. Medication was immediately secured in designated cabinet. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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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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: 02/10/2023

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LPA measured water at faucets accessible to residents and measured at 117.4 degrees F which is within Title 22 Regulations. All exit doors were inspected with auditory alarms fully functioning for residents with dementia.

Licensee, Cecilia Ganzon's Administrator Certification is expired as of 7/28/2022, however documents have been submitted for re-certification. Licensee was notified by the Department of current delay on processing. Licensee will submit renewed Administrator Certification to CCLD once received.

Infection Control:
Facility has submitted an infection control plan for review. Posters have been placed at the front door, and facility has a station near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. There is a sufficient amount of PPE supplies available. All staff and visitors were observed to have appropriate face coverings and following facility COVID protocols. Residents and staff are also screened for symptoms on daily and based on observation.

LPA requested the following documents be sent to CCL by COB 2/24/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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