486801137-9-28-2023-21-AS-CFOR-CW52U8-20230928174155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801137
Report Date: 09/28/2023
Date Signed: 09/28/2023 05:42:06 PM

Document Has Been Signed on 09/28/2023 05:42 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:	ST. JOSEPH CARE HOME-B		FACILITY NUMBER:	486801137
ADMINISTRATOR:	HELEN RABAGO		FACILITY TYPE:	740
ADDRESS:	1405 DONNER PASS DRIVE		TELEPHONE:	(707) 980-7833
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	6	CENSUS: 4	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Helen Rabago, Administrator		TIME COMPLETED:	06:15 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	Licensing Program Analyst (LPA), Carol Fowler is conducting an Required-1 Year inspection, on 9/28/2023 at approximately 02:00pm, and met with Helen Rabago, Administrator. LPA observed two on duty during the inspection. Currently four (4) client in care. Facility has an approved fire clearance four (4) ambulatory and (2) two bedridden clients. The facility has required emergency disaster plan. Facility scheduled evacuation fire drill was conducted on 07/12/2023, including staff & client. Client,1 out of 1, special diets regarding food are followed per staff interviews, and per LPA's observations during the inspection. The LPA reviewed four (4) staff files. Administrator certificate for Helen Rabago is current-#6021326740, expires 10/28/2024. All staff have required criminal record clearance. All staff have required training. The LPA reviewed four (4) client files. Client files were complete. The LPA toured the facility with the Administrator. All exits were unobstructed. The facility fire extinguisher was serviced and tagged as required expires 04/08/2023. Facility had six (6) smoke alarms, and all were working properly when checked during the inspection. Facility had one (1) carbon monoxide detector that were working properly when checked during the inspection. Facility had a first aid kit stored in the hallway storage, it did have a required first aid booklet. The facility had a sufficient supply of perishable and nonperishable food. Continue on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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 09/28/2023 05:42 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: ST. JOSEPH CARE HOME-B	FACILITY NUMBER: 486801137
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having toxins unlocked which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator locked cabinet with toxins during visit. Deficiency cleared during visit.

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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 05:42 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: ST. JOSEPH CARE HOME-B	FACILITY NUMBER: 486801137
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not having herself or staff working without a current CPR/1st aid certificate which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Administrator to ensure that at least one staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that all staff have been certified for CPR per regulation and that facility will maintain a staff on duty who has CPR training at all times and copy of certification for S1 & S2 by POC due date.

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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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: ST. JOSEPH CARE HOME-B	FACILITY NUMBER: 486801137
	VISIT DATE: 09/28/2023

NARRATIVE

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The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be clean and orderly during the visit. The LPA observed that resident rooms, common areas, hallways, and bathrooms had sufficient lighting for clients in care. Clients rooms had required accommodations per regulations. Facility had all medications locked up and inaccessible to clients in care as required.

During the tour LPA observed the following deficiencies:

unlocked toxins (cleaning supplies)
no staff member who has cardiopulmonary resuscitation (CPR) training and first aid training on duty

LPA is requesting the following forms be updated and submitted to CCL by 10/11/23:

· LIC 500 -Personnel Report
· LIC 610 - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificate
· Infection Control Plan If updated

Control of property

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 copy of report and appeal rights given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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