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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803285
Report Date: 08/23/2022
Date Signed: 08/24/2022 10:47:12 AM


Document Has Been Signed on 08/24/2022 10:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:C & F SENIOR CARE HOMEFACILITY NUMBER:
486803285
ADMINISTRATOR:FOJAS, LINAFACILITY TYPE:
740
ADDRESS:1120 SONGWOOD ROADTELEPHONE:
(707) 246-0867
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lina FojasTIME COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Lina Fojas. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 5 residents in care. This facility is licensed for 6 non ambulatory residents, with hospice waiver approved for 3 of the residents and none of the residents are approved for bedridden.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels and required hand washing postings. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 2/5/2021. Facility has also submitted their Infection Control plan, that will be part of their plan of Operation. Caregivers have completed PPE training but have not been N-95 Fit tested. In addition, facility was found to be at a comfortable temperature. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged and purchased on May 25, 2022.

LPA went over reporting requirements for incident reports to be submitted to CCL within 7 days. During todays visit LPA discovered facility has had several resident incidents and a Death report that has not been submitted and facility has also failed to notify Community Care Licensing (CCL) of new Hospice intake as required. Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285
VISIT DATE: 08/23/2022
NARRATIVE
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LPA toured the 2nd floor of the facility, there is a rope across the bottom of the stairs to prevent access to any residents going up. The top floor is not used by residents, LPA observed two bedrooms in the second floor.
The first floor of the facility has 4 bedrooms that were approved for residents to use. Bedroom #1 has an adjacent room before entering room #1 and that room was not identified as a bedroom and the facility has a twin bed set up.
LPA requested staff open a locked closet door in resident room #4 and observed two twin beds set up as an L shape with personal belongings, clothing, shoes, cell phones charging, personal medications and framed picture. The master bedroom closet for resident (R1) was being used as a staff bedroom. Facility immediately removed both beds and all personal belongings during LPA'S visit. This is an immediate Fire safety violation, Zero tolerance and a civil penalty was issued in the amount of $500.00 during today's inspection.
The staff beds in the first level of the home where removed, Administrator was advised, the facility will need to ensure they have awake staff during the night to provide care and supervision to all resident in the first level of the home until the facility can install a call button system that can alert the staff in the second level of the facility; where staff bedrooms are located. Administrator to inform CCL LPA once auditory call system has been installed.

LPA requested the following updated records to be submitted to Community Care Licensing (CCL) 9/19/2022.
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610 Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Copy of administrator certificate; Copy of liability insurance; Copy of current Lease/Rental Agreement

See report LIC809-D for Deficiencies 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. Appeal rights were provided. A civil penalty was applied for $500.00 for fire safety, Zero Tolerance. Exit interview conducted with Lina Fojas.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 08/24/2022 10:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203- Fire Safety -All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection LPA observed a master closet for resident R1 was being used as a staff bedroom. The room contained 2 small beds and personal belongings for staff. In addition a room adjacent to bedroom 1 was not identified as a bedroom and does not have a fire clearance and also contained a bed. LPA went over observations with Lina Fojas, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty for $500.00 was issued during today's inspection for Fire Safety Violation, Zero Tolerance.
POC Due Date: 08/24/2022
Plan of Correction
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Facility to send in a written statement that they understand regulation, facility removed all items from master bedroom 4 closet during inspection. Facility also removed bed from room adjacent to resident room 1 during today's inspection.
POC due date 8/24/2022
Type A
Section Cited
HSC
1569.269(a)(6)
1569.269(a)(6) (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection LPA observed resident R1 had a reclining chair placed infront of their bed to prevent resident from getting up. Staff S1expressed they had just put it because R1 is a fall risk and tries to get up. LPA went over resident personal right and explained staff must be sufficient to observe and meet residents needs. Staff S1 pushed the large recliner away, during the inspection. The licensee did not comply with the section cited above in 1 of 5 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Facility to send in written plan on how they will meet regulation and meet resident R1's needs. Facility to send in proof of staff training.

Plan of correction (POC) due date for written statement due 8/24/2022 and proof of staff training due 8/29/2022. POC to be sent to CCL attention LPA A Canela

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/24/2022 10:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: C & F SENIOR CARE HOME
FACILITY NUMBER: 486803285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements 87211(a)(1) (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection and records review, the licensee did not comply with the section cited above in several incident reports and Death report for resident (R2) not reported to community care licensing (CCL). Facility had incident reports LIC624 forms but never sent them to CCL. LPA reviewed facility file & facility has not reported any incident or death rpts for 2022
POC Due Date: 08/31/2022
Plan of Correction
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Facility to send in written statement on how they will stay in compliance and that they understand reporting requirements regulation and submitt all incident resident reports that were not reported to CCL, attention LPA Canela by 8/31/2022
Type B
Section Cited
CCR
87632(d)(2)
Hospice Care Waiver- 87632(d)(2) (d)If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection and record review with administrator Lina Fojas, the licensee did not comply with the section cited above in 1 of 1 records reviewed for resident R2 who was placed on Hospice and the facility failed to notify CCL within 5 days, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Facility to send in written plan on how they will stay in compliance and that they understand regulation requirement along with all residents who are on Hospice and where not reported to CCL. POC due date 8/31/2022 to LPA A Canela

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4