486802066-7-19-2024-21-AS-ACAA-D7C2R5-20240719173658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486802066
Report Date: 07/19/2024
Date Signed: 07/19/2024 05:38:12 PM

Document Has Been Signed on 07/19/2024 05:38 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:	CLARIN'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	486802066
ADMINISTRATOR:	CLARIN, JULIANA		FACILITY TYPE:	740
ADDRESS:	3024 CLEAR COAST COURT		TELEPHONE:	(707) 557-6837
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 2	DATE:	07/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Juliana Clarin, Administrator		TIME COMPLETED:	03:45 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), Araceli Canela arrived at Clarin's Residential Care Home for the purpose of conducting a Required-1 year inspection. LPA met with licensee/Administrator, Juliana Clarin and toured the inside and outside of the home. This facility is licensed for 6 non-ambulatory residents, with approval for 3 of the residents to receive Hospice services and there is no approval for bedridden. LPA toured the home and found the home to be at a comfortable temperature with all exits free from obstruction. This home is a two story home and the second level of the home is used by staff and there is a gate at the bottom of the stairs to make the second level inaccessible to residents. There are a total of 3 bedrooms in the first level of the home that are used by residents. Residents have working auditory devices to use, to call for assistance. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the kitchen was observed charged and serviced August 9, 2023. There are auditory alerts on exit doors. Water temperature in the resident bathrooms were tested and found to be at 125 degrees F. and Not within appropriate range of 105-120 degrees. LPA requested facility to lower the water temperature. R1 & R2 are both using wheelchairs and staff assist the residents when they are in the bathroom, citation lowered to a type B at this time. Administrator was advised failure to keep the water temperature below 120 will result in the facility being issued a type A citation because of the immediate danger to the health and safety of residents in care. Bathrooms have the required non-skid surfaces and grab bars. Knives are stored in a locked cabinet in the kitchen. There is adequate space and furniture on the patio for outdoor activities. There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. There is a locked cabinet that stores residents' medications, staff and resident files. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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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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: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
	VISIT DATE: 07/19/2024

NARRATIVE

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LPA reviewed staff files and staff have proof of current CPR/1st aid that expire 7/28/25 and 4/8/2026. Administrator certificate for Juliana Clarin #6022329740 expires 1/31/2025.

Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan. LPA went over Reporting Requirements.

Licensee/Administrator to submit the current following documents by 8/20/2024:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of current Liability Insurance

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2024 05:38 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: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs inspection and testing of the bathroom water with Administrator, showed a temperature of 125 degrees F. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	Facility to label any faucets that could potentially dispense water above 125 degrees. Facility to lower water temperature and ensure it is maintained below 120 degrees. Facility to send in writen statement they understand regulation and weekly water temperature log as proof. POC due date and log to be submitted by 8/19/2024 attention LPA A Canela

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: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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