486800782-8-29-2023-21-AS-ACAA-CV73HE-20230829181548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800782
Report Date: 08/29/2023
Date Signed: 08/29/2023 06:16:51 PM

Document Has Been Signed on 08/29/2023 06:16 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:	D HILLSIDE PLACE II		FACILITY NUMBER:	486800782
ADMINISTRATOR:	COPERO, JOHNNY		FACILITY TYPE:	740
ADDRESS:	103 MICHAEL CT.		TELEPHONE:	(707) 552-7584
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:29 PM
MET WITH:	Mylene Copero, co licensee & Administrator		TIME COMPLETED:	05:01 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	Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with care staff, Mark Sambayan and Mark Padilla. Mylene Copero, co licensee and Administrator arrived few minutes later. This facility is licensed for 6 Non-ambulatory residents with a Hospice Waiver approved for 1 of the residents and no Bedridden approval. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 degrees F which is within the required range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Closet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies. Fire extinguishers were fully charged and last serviced February 9, 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drill was conducted 8/10/2023. Staff have required First Aid and CPR certificates that expire in 2024. Certificate for Administrator, Johnny "Juanito" Copero, 6017113740, expires on 6/11/2024. Training records were reviewed. Required postings were observed. Medication records were reviewed. Continued Report see LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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: D HILLSIDE PLACE II	FACILITY NUMBER: 486800782
	VISIT DATE: 08/29/2023

NARRATIVE

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Two staff files and six resident files were reviewed. Resident files for R1 and R2 were found to not have a current Physician Report (LIC602), last report in file for R1 was documented on 9/2020 and R1 has Dementia diagnoses. R2's Was documented on 6/2022 and was also over a year old and not within the required 1 year for residents diagnosed with Dementia. Yearly Appraisal were also not current.

LPA consulted regarding Reporting Requirements, no use of garage for sleeping, Not using a pad lock to lock gates unless they have been approved for locked perimeter from Community Care Licensing and the Vallejo Fire department.

Licensee/Administrator to submit updates of the following documents by 9/28/2023:

LIC 500 Personnel Summary-
LIC308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)
Copy of Liability Insurance
Copy of Administrators Certificate
COPY of updated Facility sketch

The following deficiencies were observed (see LIC 809-D) and cited 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 and appeal of rights provided by email.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 06:16 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: D HILLSIDE PLACE II	FACILITY NUMBER: 486800782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(1)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation on todays inspection, R2 was observed with a half/full bed rail. Licensee explained that there was a doctors order for the use, but could not locate. The licensee did not comply with the section cited above in 1 out of 6 residents requirements for the use of postural supports, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2023
	Plan of Correction
1 2 3 4	Facility to provide proof of the use of the half bed rail and send in a written statement they understand full bed rails are not to be used; written plan to include R2s plan to ensure their safety, current appraisal showing needs and service plan. POC due date 9/20/2023 to LPA Araceli Canela

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays record review with co-licensee, Mylene R1 and R2 with dementia diagnoses did not have a current physicians report and appraisal. Facility also needed current reappraisals for 4 out of 5 residents, and 2 out of 5 residents physician reports were dated to have been conducted in 2017 and 2018, the licensee did not comply with the section cited above in 3 out of 6 resident records, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Facility to send proof of residents current physician reports, reappraisal, Service needs and written statement they understand regulation. Statement to include plan on how they will stay in compliance. POC due date 9/28/2023 attention LPA Araceli 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	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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