486801788-5-24-2022-21-AS-DTOA-CEQS9W-20220524134125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801788
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:48:05 PM

Document Has Been Signed on 05/24/2022 01:48 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 MANOR II		FACILITY NUMBER:	486801788
ADMINISTRATOR:	GUBA,ALMABELLA		FACILITY TYPE:	740
ADDRESS:	841 ROLEEN DRIVE		TELEPHONE:	(707) 315-4427
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS:	DATE:	05/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Alma Guba, Licensee		TIME COMPLETED:	02:00 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) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Licensee, Alma Guba (AG).The facility currently provides care for six (6) residents some of which with a diagnosis of dementia and one of which on hospice. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; facility was found to be clean and 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 3/17/2022 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored securely in designated staff quarters. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water measured between 114.1 and 117.5 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. LPA also confirmed that all staff have updated 1st Aid & CPR Training on file. During the tour LPA observed resident R1 with the use of bed rails. LPA reviewed facility resident Physician's Reports and found that R1 is determined to be bedridden. Facility does not have an approved fire clearance to provide care for a bedridden resident. LPA was informed that Licensee was aware of the bedridden status but was not aware that a fire clearance request was needed prior to R1's admission. LPA and Licensee discussed fire clearance requests and plan of care for resident R1 while the request is being processed. Continued onto LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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: ALMABELLA MANOR II	FACILITY NUMBER: 486801788
	VISIT DATE: 05/24/2022

NARRATIVE

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LPA requested the following documents be sent to CCL by COB 5/31/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Infection Control:
Facility has submitted a mitigation program plan which has been approved. All staff and residents have been fully vaccinated and boosted with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened on a daily basis.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2022 01:48 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 II	FACILITY NUMBER: 486801788
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 1 out of 1 residents with a bedridden status while facility does not have appropriate fire clearance. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee agrees to contact the local fire department and request for an updated fire clearance for residents that are currently bedridden. Update fire clearance is to be submitted to CCLD by POC due date 6/1/2022. In addition, Licensee agrees to provide plan of care in writting of how the facility staff will provide adequate care for bedridden residents until fire clearance is granted or more appropriate placement is found. Written plan of care is to submitted to CCLD by POC due date 5/25/2022.

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: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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