486803119-8-14-2024-21-AS-JFLO-D7QUBY-20240801152706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803119
Report Date: 08/01/2024
Date Signed: 08/14/2024 08:44:46 AM

Document Has Been Signed on 08/14/2024 08:44 AM - 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:	C & C RESIDENTIAL CARE HOME INC.		FACILITY NUMBER:	486803119
ADMINISTRATOR:	CORSIGA, ALMA		FACILITY TYPE:	740
ADDRESS:	2018 BLUEBIRD WAY		TELEPHONE:	(707) 344-2628
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	08/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alma Corsiga, Licensee		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	At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and was greeted by a caregiver. Alma Corsiga, Licensee, was contacted by phone and arrived at approximately 9:45 AM. LPA was informed there were six (6) residents in care; two (2) were away at Day Program and four (4) were present during inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with an approved dementia plan and fire clearance for capacity of six (6) non-ambulatory residents. At approximately 10:00 AM, LPA initiated a tour of the facility and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. LPA observed three residents in their respective beds. Two of whom showed their ability to move and reposition themselves. Cabinets in communal areas containing cleaning supplies and other items that could pose a risk were observed unlocked. Licensee had staff remove the items immediately and place them in a locked cabinet. Facility has at least two days of perishable foods and a supply of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. LPA observed toys, games, video games, and an ipad for resident use. Facility has a fire extinguisher, which was last inspected May 2024 as is fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Continued on 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: C & C RESIDENTIAL CARE HOME INC.	FACILITY NUMBER: 486803119
	VISIT DATE: 08/01/2024

NARRATIVE

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Continued from LIC 809...

At approximately 12:15 PM, five (5) resident files were reviewed. LPA observed one (1) resident (R1) file with a physician's medical assessment from May 2024 indicating said resident is bedridden. Facility's fire clearance does not contain approval for bedridden residents. LPA observed 3 of 5 resident files missing the required I.D. and Emergency Information form and 5 of 5 resident files were missing consent for emergency medical treatment. LPA observed all the remaining required documentation per regulation in five (5) of five (5) resident files. Licensee states facility coordinates the residents' medical and dental appointments as needed and provides transportation to and from these visits.

At approximately 1:45 PM LPA initiated file review of five (5) personnel files but was unable to complete the review. LPA was also unable to review medications, P&I, and facility's emergency disaster drill log and will return at a later date to complete annual inspection.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights provided to Licensee.

Exit interview conducted with Licensee, whose signature on this document confirms receipt.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC 200 Request for Bedridden Fire Clearance
LIC 999 Updated Facility Sketch
LIC 500 Personnel Record (updated)
LIC 610 Emergency Disaster Plan (updated)
LIC 9020 Register of Facility Resident’s
Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2024 08:44 AM - 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: C & C RESIDENTIAL CARE HOME INC.	FACILITY NUMBER: 486803119
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.72

1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (a) …no resident shall be admitted or retained in a residential care facility for the elderly if…(2) [t]he resident is bedridden, other than for a temporary illness or for recovery from surgery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring a bedridden resident is not retained which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee to submit LIC 200 requesting updated fire clearance to include approval to retain one (1) bedridden resident, along with an updated facility sketch by POC due date 8/2/2024, close of business (COB).

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia.... toxic substances such as...disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring toxic chemicals remain inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Licensee removed the items immediately and secured them in a locked cabinet. POC cleared 8/1/2024.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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