486801899-8-12-2021-21-AS-KWAS-C5TMQG-20210812094840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801899
Report Date: 07/22/2021
Date Signed: 08/12/2021 09:48:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	GOLDEN HAVEN CARE HOME II		FACILITY NUMBER:	486801899
ADMINISTRATOR:	LUBUGUIN,ROSALINA		FACILITY TYPE:	740
ADDRESS:	900 MURRE WAY		TELEPHONE:	(707) 421-1386
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 4	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Facility Staff, Prima Eudelyn Rabana		TIME COMPLETED:	02:10 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) Katrina Walters conducted an unannounced Annual Required – 1 year Infection Control inspection visit to this facility and was greeted by Staff, Prima Eudelyn Rabana (PER). The Administrator, Rosalina Lubuguin (6010923740 exp. 2/09/2022) was not available for today's visit. A risk assessment was done prior to entry. At the time of inspection there were two staff providing care and supervision for four residents. The inspection is focused on the Infection Control procedures and practices of this facility. This facility has submitted a COVID-19 mitigation plan to Community Care Licensing, that was approved on 7/22/21. LPA observed that the facility is following the following mitigation plan policies: Upon entry, LPA was signed into the facility sign-in sheet and had temperature checked and logged into a binder. LPA advised that the screening questions be added to the sign in sheet. Resident's temperatures are logged in a separate binder. There was one entry point for the facility. LPA toured the facility with staff. Signs were posted throughout the facility to promote social distancing and hand washing. During facility tour the facility was found to be clean and at a comfortable temperature. Alcohol based hand wash was available in each client's room and throughout the facility. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GOLDEN HAVEN CARE HOME II	FACILITY NUMBER: 486801899
	VISIT DATE: 07/22/2021

NARRATIVE

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Continued from 809

Facility has Personal Protective Equipment (PPE) stored in a spare bedroom. Clients’ medications are stored in a locked cabinet in the dinning room. Facility has at least 30-day supply of medication for clients based on pharmacy supply and refill practices. During inspection, LPA also observed three sets of medication pre-poured in plastic cups. (pictures taken). LPA confirmed the medication was for their PM 7/22, AM 7/23 and PM 7/23. LPA explained regulations regarding pre-pouring medications. This violation to regulation is being cited on LIC 809-D.

LPA is requesting that the Administrator sends the following updated forms to Community Care Licensing attention LPA Walters 7/30/21: Updated Personnel Report (LIC 500) and an Updated Emergency Disaster Plan (LIC 610 E).

California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC- 809D. Exit interview conducted with Staff, Appeal Rights provided. The signature below confirms receipt.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GOLDEN HAVEN CARE HOME II	FACILITY NUMBER: 486801899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/27/2021 Section Cited	1 2 3 4 5 6 7	80075(k)(5) Health Related Services - Each client's medication shall be stored in its originally received container.This requierment was not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation and interview conducted, Licensee did not ensure medications were not pre-poured and out of original container for 4 or 4 residents. This is an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

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