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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800091
Report Date: 11/02/2023
Date Signed: 11/02/2023 05:37:52 PM

Document Has Been Signed on 11/02/2023 05:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AVELINA FRANCISCA CARE HOME IIFACILITY NUMBER:
486800091
ADMINISTRATOR:BAYLEN, FLORESFACILITY TYPE:
740
ADDRESS:107 SANDPIPER DRIVETELEPHONE:
(707) 645-1444
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Meriam Vera, CaregiverTIME COMPLETED:
06:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 11/02/2023 at approximately 1:50PM, and met with Meriam Vera, Caregiver and Cristina L. Mallari, Administrator and Rogie Mallari arrived at approximately 2:35PM. Administrator Certificate, #6056795740, is current- expires 03/21/2025. LPA observed two caregivers working at the time of arrival. There are currently four (4) residents in care.

Facility has a required infection control plan. Facility has an emergency disaster plan as required.
All exits were free and clear of obstruction. Fire extinguisher, was last serviced on 12/1/2022 and tagged as required. LPA observed ten (10) smoke alarms with carbon monoxide detector, working properly during the inspection.

Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 116.9 F, which is within regulation. Medications were stored and locked making them inaccessible to residents.

There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed.



Deficiencies observed during inspection:
  • unlocked scissors, screw driver, lighter, tools, lighter, laundry soap
  • bed, bed rails, cement blocks, wood planks with metal rod
  • Hoyer lift, wheelchairs, dolly,
  • low food supply, disaster drills not conducted timely


Continue on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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Document Has Been Signed on 11/02/2023 05:37 PM - It Cannot Be Edited


Created By: Carol Fowler On 11/02/2023 at 04:40 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: AVELINA FRANCISCA CARE HOME II
FACILITY NUMBER: 486800091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 by having scissors, screw driver and other tools, laundry detergent and lighter accessible which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Administrator and Licensee removed items and placed them in a locked cabinet during inspection. Deficiency cleared during visit.
Type A
Section Cited
CCR
87555(b)(26)
87555(b)(26) General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's observations, there was a low supply of sufficient perishable and non-perishable foods to meet the needs of the four clients meals and snacks, the licensee did not comply with the section cited above, which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee/Administrator to ensure there is a sufficient supply of perishable and non-perishable foods on-site at all times; Ensure to have a food supply that is able to provide residents with nourishing meals and snacks as required. Licensee to ensure food is bought for the facility in a sufficient supply for the faciility operation. Submit a copy of the food purchase receipt, photos and a written self certification that the food is for the facility by POC date
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/02/2023 05:37 PM - It Cannot Be Edited


Created By: Carol Fowler On 11/02/2023 at 04:40 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: AVELINA FRANCISCA CARE HOME II
FACILITY NUMBER: 486800091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 by not conducting quarterly drills which poses a potential health and safety risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Licensee/Administrator agreed to conduct a disaster drill no later then the POC date and send certification of attendees.
Type B
Section Cited
CCR
87307(d)(4)
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

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 by having beds, bedrails, cement blocks, wheelchairs, dolly, hoyer lift, and other items located on the open porches which poses a potential health and safety risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Licensee/Administrator agreeded to read the regulation self certify and remove items from the open porche no later then the POC date.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AVELINA FRANCISCA CARE HOME II
FACILITY NUMBER: 486800091
VISIT DATE: 11/02/2023
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Continue from LIC809


LPA will return at a later date to conduct interviews, and a pre-licensing visit.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted and a copy of this report and appeals right provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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