486802064-6-28-2024-21-AS-SMUU-D6P364-20240628175743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486802064
Report Date: 06/12/2024
Date Signed: 06/28/2024 05:57:51 PM

Document Has Been Signed on 06/28/2024 05:57 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:	COMFORT LIVING FOR SENIORS II		FACILITY NUMBER:	486802064
ADMINISTRATOR:	SADDI, DONABELL W.		FACILITY TYPE:	740
ADDRESS:	685 PURPLE MARTIN DRIVE		TELEPHONE:	(707) 410-9706
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	6	CENSUS: 6	DATE:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Mildred Mamaradlo, Caregiver		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	At approximately 1:40 PM on 06/12/2024, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by caregiver, Mildred Mamaradlo, Caregiver. Administrator, Donnabell is out of the country. The facility is a single story home licensed for six (6) non-ambulatory residents and hospice waiver capacity of two (2). The facility currently provides care for six (6) residents. Six out of six residents were at home and six out of six residents were eating or watching television for leisure. In addition, there are six (6) residents with a diagnosis of dementia and one resident on hospice. At approximately 2:00 PM, LPA and caregiver toured the building and grounds which was found to be clean and in good repair. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room and kitchen .LPA observed insect killer in backyard accessible to residents. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 111 and 114 degrees F at six of six faucets accessible to residents. One of One Fire extinguisher inspected was charged. Four of four Smoke detectors and One of one Carbon Monoxide detector was present and inspected. Disaster Drills are conducted quarterly with the last drill conducted 06/2024. There was enough lighting in all common areas, resident rooms, and hallways. LPA to continue annual at a later date. Continued on 809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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 06/28/2024 05:57 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: COMFORT LIVING FOR SENIORS II	FACILITY NUMBER: 486802064
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

This requirement is not met as evidenced by: 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. This requirement was not met as evidence by:**
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation insect killer/poison was found unsecured in the backyard which poses an immediate threat to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2024
	Plan of Correction
1 2 3 4	Caregiver failed to ensure that toxins, medications, and other items that could constitute a danger to the resident(s) were stored inaccessible to residents in care with dementia. Caregiver immediately locked the items in designated cabinets. In addition, Licensee is to submit plan to train staff on how toxins, chemicals, medications, and cleaning supplies are kept secured and submit a Proof of Corrections to CCLD by POC due date 06/13/24

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: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: COMFORT LIVING FOR SENIORS II	FACILITY NUMBER: 486802064
	VISIT DATE: 06/12/2024

NARRATIVE

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Continued from 809

At approximately 4:00 PM on 06/28/2024 , Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual continuation required inspection of this licensed senior care facility. LPA was greeted by caregiver, Mildred Mamaradlo,( MM) provided LPA with Client and staff files. Administrator, Donabell Saddi arrived shortly after.

At approximately 04:15 PM, LPA reviewed 6 of 6 Client records which were all found to be well organized , thorough, and contained the required documentation. LPA reviewed 4 of 4 Staff records, which were all found to be well organized but did not contain the required documentation, 4 of 4 staff files missing LIC501 and 2 of 2 staff records are missing LIC503-Medical Assessment and TB screening. Administrator to provide to CCLD, LPA advised Administrator all staff records must be kept at facility at all times. First aid and CPR certification were current in staff files reviewed. Administrator's Certificate is expired as of 04/28/2024 and pending per documentation provided from CDSS CCLD website.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610D- Disaster Plan (updated with non-local evacuation site)
Resident Roster
LIC501
LIC503/TB Screening

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

Appeal rights were given on 06/12/2024

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie Mutialu	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC809 (FAS) - (06/04)

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