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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801381
Report Date: 02/07/2023
Date Signed: 02/07/2023 09:31:42 PM


Document Has Been Signed on 02/07/2023 09:31 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:ALMABELLA MANORFACILITY NUMBER:
486801381
ADMINISTRATOR:GUBA, ALMABELLAFACILITY TYPE:
740
ADDRESS:3323 TENNESSEE ST.TELEPHONE:
(707) 645-7389
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Samantha RayTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) A. Canela arrived at Almabella Manor for the purpose of doing a prelicensing inspection for a change of ownership for new applicant Agape Collins' Care Home. During the inspection LPA observed staffs bedroom is not locked and LPA entered and observed prescription medication and vitamin bottles next to staffs bed. Items belong to the staff, but are not locked and they are accessible to residents in the facility. LPA previously consulted with licensee Alma Bella Guba and new applicant in regards to addressing staffs bedroom and providing a locked box for them to place any items that need to be inaccessible to residents and residents with dementia or ensure staffs bedroom door maintains locked at all times.


Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, Samantha Ray. Appeal rights provided.

Due to printer issues, this report was emailed to Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/07/2023 09:31 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: ALMABELLA MANOR
FACILITY NUMBER: 486801381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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87705(f)(2) Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Facility to send in written statement they understand regulation and how items will be inaccessible. Facility to provide and send proof of staff training.
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During today's inspection LPA observed staff bedroom not locked and there were bottles of vitains and a prescription medication acessible to residents in care. This is an immediate risk to the health and safety of resident in care.
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Written statement of plan due by 2/8/2023 and staff training due by 2/10/2023.
Attention LPA Araceli Canela

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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
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