486800368-11-15-2024-21-AS-JFLO-DB35R6-20241115191036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 11/15/2024
Date Signed: 11/15/2024 07:10:45 PM

Document Has Been Signed on 11/15/2024 07:10 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:	PARADISE VALLEY ESTATES		FACILITY NUMBER:	486800368
ADMINISTRATOR/ DIRECTOR:	YEE, KELLY		FACILITY TYPE:	741
ADDRESS:	2600 ESTATES DRIVE		TELEPHONE:	(707) 432-1100
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 743	TOTAL ENROLLED CHILDREN: 0	CENSUS: 69	DATE:	11/15/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Kelly Yee, Administrator		TIME VISIT/ INSPECTION COMPLETED:	07:20 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	At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Kelly Yee, Administrator. Facility is a Continuing Care Retirement Community (CCRC) with a combined total of 69 residents currently residing in the assisted living and memory care units. The community is approved for a total capacity of 743 residents, of which 223 residents may be non-ambulatory. The community has a Hospice waiver for 6 residents, and there is an approved delayed egress system in place in the memory care unit. At approximately 10:10 AM, LPA initiated a tour of the community's Quail Creek and Willow Creek Assisted Living Facilities and the Deer Creek Memory Care Facility and observed the following: The Quail Creek facility is a three story building and the Willow Creek and Deer Creek facilities are both one story. Each building was a comfortable temperature, and passageways were free from obstructions. LPA observed the required evacuation chairs in stairwells. Water temperature in 4 of 16 residents' bathrooms measured outside the allowable range of 105 to 120 degrees F per Title 22 regulations, (see LIC809D). LPA observed a supply of hygiene, paper, and incontinent care products available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets and storage rooms containing cleaning supplies and other items that could pose a risk were locked. Community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Food was covered, labeled, and stored in accordance with regulation. LPA advised the head chef in both the Quail Creek and Willow Creek kitchens to ensure that all expired food is consumed or disposed of by the expiry date. Medications were centrally stored and locked. The community has a fitness center with a class schedule posted with multiple classes per day offered to residents, an indoor pool, tennis courts, a massage room, a beauty salon, daily activities, crafts, puzzles, music, movies, reading areas, and more for residents in care. Continued on LIC809-C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY ESTATES	FACILITY NUMBER: 486800368
	VISIT DATE: 11/15/2024

NARRATIVE

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Continued from LIC809...

There are covered patios and seating areas throughout the community with outdoor space for activities.
The community has internet service available to residents in care.

The community's fire extinguishers were observed charged and were last serviced 11/2023. Smoke and Carbon Monoxide detectors were last inspected 6/2024 and are inspected semi-annually. The automatic sprinkler system is inspected semi-annually and was last inspected 8/2024. The community conducts regular monthly disaster drills, and the most recent drill was conducted 10/2024. LPA observed the community's infection control plan and the emergency disaster plan which was last updated 12/2023. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid bag in each building. Administrator states the community has several back up generators.

At approximately 12:30 PM, LPA began file review of 10 staff files and 10 resident files. 7 out of 10 resident files reviewed did not have the Needs and Services Plan signed and dated by the resident and/or their responsible party, (see LIC809D). Administrator advised to ensure all forms are signed and dated, including consent for emergency medical treatment and personal rights. 10 out 10 resident files reviewed had all the remaining required documentation. 7 out of 10 staff files reviewed were missing the required first aid training, (See LIC809D). 4 of 10 staff files reviewed were short of the some of the specific annual training hours required, (see LIC809D). LPA advised Administrator to ensure that the required initial training hours are documented in accordance with regulation. 10 out 10 staff files reviewed had all the remaining required documentation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC610- Emergency Disaster Plan
A copy of community Liability Insurance

The following deficiencies were observed and cited (see LIC 809-Ds) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with Administrator whose signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 07:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY ESTATES	FACILITY NUMBER: 486800368
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 out of 16 bathroom faucets tested which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	Administrator to self certify that they will ensure all faucets accessible to residents in care dispense water within the allowable to range of 105-120 degrees F per regulation to CCL by POC due date 11/18/2024. Administrator to submit a five day water temperature testing log to CCL by POC due date 1/15/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 07:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY ESTATES	FACILITY NUMBER: 486800368
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Participation in Decisionmaking

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 7 out of 10 resident files reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Administrator to submit signed Needs and Services Plans for the 7 residents to CCL by POC due date 01/15/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 07:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY ESTATES	FACILITY NUMBER: 486800368
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 10 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Administrator to submit proof of category specific annual training hours completed for the 4 staff to CCL by POC due date 01/15/2025.

Section Cited

Personnel Requirements - General: 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 7 out 10 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Administrator to submit proof of first aid training completion for the 7 staff to CCL by POC due date 01/15/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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