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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800888
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:03:09 PM

Document Has Been Signed on 02/03/2023 01:03 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:MED RESIDENTIAL CARE HOME IIFACILITY NUMBER:
486800888
ADMINISTRATOR:VERANO, MATILDAFACILITY TYPE:
740
ADDRESS:1243 GRANADA ST.TELEPHONE:
(707) 552-8550
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 6DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Matilda Verano, LicenseeTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by lead staff, Mercedita Manalo; Licensee, Matilda Verano was contacted and arrived later in the visit. The facility currently provides care for 6 residents all of which were present at the time of visit. There are currently 2 residents 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 Extinguishers were found to be last charged on 1/20/2023 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 and labeled properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be resting in their respective bedrooms or in the kitchen area participating in art activities. 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 under kitchen sink found to be secured. LPA observed sliding door auditory alarm sound to be low and in need of battery replacement. Technical Violation issued. Licensee to submit LIC9098 Proof of Corrections to CCLD. Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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: MED RESIDENTIAL CARE HOME II
FACILITY NUMBER: 486800888
VISIT DATE: 02/03/2023
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During the inspection LPA Tobola found that resident (R1) had recently been diagnosed as bedridden but currently in a non-bedridden cleared room. The Licensee has been working with Fire Inspector to update fire clearance and potentially modify exits. Upon review of resident (R1) records, LPA found that R1 was deemed bedridden due to ulcers. However, the ulcers were temporary and have been healed. Licensee agrees to update R1's Physician's Report to determine ambulation status. In addition, Licensee will provide updates to CCLD regarding Fire Clearance decision. LPA requested for Fire Inspector contact information to follow up.

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. All staff and visitors were observed to have appropriate face coverings and following facility COVID protocols.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 2/17/2022:

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
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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