486802066-7-24-2023-21-AS-ACAA-CU344P-20230724184640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486802066
Report Date: 07/21/2023
Date Signed: 07/24/2023 06:48:32 PM

Document Has Been Signed on 07/24/2023 06:48 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:	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: 3	DATE:	07/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:42 PM
MET WITH:	Juliana Clarin, Licensee		TIME COMPLETED:	05:13 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 bed ridden. 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 storyClarin's Residentoa; 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. LPA went over requirements for facility to have an auditory device for residents to use to call for assistance. The device must me working at all times for resident to be able to communicate or facility will ensure there is awake staff at night. LPA went over the importance to ensure the safety and for resident to be able to communicate and request assistance when needed. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the kitchen was observed charged and serviced June 8, 2023. Fire drill was conducted by the facility and documented on May 2023. There are auditory alerts on exit doors which were tested and functional. Water temperature in the resident bathrooms were tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in a locked cabinets 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: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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: 07/21/2023

NARRATIVE

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Medication was reviewed and in compliance. LPA reviewed staff files and staff S1 did not have proof of current CPR/1st aid as it had expired May of 2023. 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 and requested facility to go over the Hospice Waiver that is in place for the facility. The facility must must remain in substantial compliance with all terms and conditions of the waiver and notify the Department in writing within five working days of the initiation of hospice care services in the facility for any terminally ill resident. The notice must include the resident’s name, date of admission to the facility, and the name and address of the hospice.

Licensee/Administrator to submit the current following documents by 8/21/2023:

· 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: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2023 06:48 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: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(i)(1)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations on todays inspection and review with Administrator, the licensee did not comply with the section cited above in 3 of 3 resident room signal systems were not properly working or did not have batteries, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Facility to send in written plan on how they will ensure a signal system is working properly at all times. Proof of correction to LPA A canela by 8/4/2023

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays record review with Administrator, S1 did not have proof of current CPR/1st aid. The licensee did not comply with the section cited above in 2 out of 2 staff did not have proof, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Facilit to send in written plan on how they will ensure staff have Proof of CPR/1st aid. Facility to send in proof of current CPR/1st aid to LPA A Canela by 8/11/2023

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: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/24/2023 06:48 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: CLARIN'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 486802066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays review of staff files with Administrator, the facility failed to ensure staff had the required annual training. The licensee did not comply with the section cited above in 1 of 1 staff training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Proof of training

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: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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