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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803084
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:01:07 PM


Document Has Been Signed on 01/11/2024 02:01 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,
, CA



FACILITY NAME:RIO VISTA CARE HOMEFACILITY NUMBER:
486803084
ADMINISTRATOR:LAQUINDANUM, MARIAFACILITY TYPE:
740
ADDRESS:185 TRINITY COURTTELEPHONE:
(707) 374-3777
CITY:RIO VISTASTATE: CAZIP CODE:
94571
CAPACITY:6CENSUS: 4DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Licensee, Maria LaquindanumTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/11/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with a licensee and explained the purpose of the visit.

LPA and licensee toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed.
LPA advised that the doorways and exits be cleared of obstructions, commonly touched surfaces be cleaned and sanitized regularly, storage areas with locks be maintained and consistently locked, and that hot water be monitored regularly as temperature was measure at 120' F.

LPA reviewed resident files. Files were found to be lacking written appraisals and care plans.
Staff files were reviewed. S1 does not have proof of 2023 training on file.

LPA requested the following documents be submitted by email to LPA: liability insurance certificate; LIC 400- Affidavit regarding Client Cash Resources (updated to reflect no cash managed); Updated Emergency Disaster Plan (LIC 610E); LIC 9020- Register of residents; and current lease agreement

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Exit interview conducted. Report copy and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: 209-814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9


Document Has Been Signed on 01/11/2024 02:01 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,
, CA


FACILITY NAME: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

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
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Based on records review , the licensee did not comply with the section cited above in records for S1 did not contain 2023 staff training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Proof of S1's required 20 hours annual training will be submitted to CCL by the POC date of 2/8/23.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 4 of 4 resident records did not contain pre-admission appraisals, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee will submit a statement of understanding of the requirement of pre-admission appraisals for all residents, by the POC date of 2/8/24
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: 209-814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 01/11/2024 02:01 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,
, CA


FACILITY NAME: RIO VISTA CARE HOME
FACILITY NUMBER: 486803084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 of 4 resident files, as they lacked needs and services plans or annual reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee will submit completed, and signed, LIC 625s for R2, R3 and R4 by the POC date of 2/8/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: 209-814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9