486803392-7-2-2024-21-AS-JFLO-D6MRQS-20240627131401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803392
Report Date: 06/27/2024
Date Signed: 07/02/2024 02:12:17 PM

Document Has Been Signed on 07/02/2024 02:12 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/01/2024 03:42 PM

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

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	***Amended LIC809-D due to technical difficulties on 6/27/2024. At approximately 9:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and met with Pritpal Atwal, Licensee/Administrator. LPA was informed there are four (4) residents in care, one (1) of which is on Hospice. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for three (3), an approved dementia plan and fire clearance for capacity of six (6) non ambulatory residents. At approximately 9:15 AM, LPA initiated a tour of the facility and observed the following: Facility is a two-story home, was a comfortable temperature, and passageways were free from obstructions. The second floor was observed gated off from resident access, and LPA was informed that the upstairs loft, closet and bathroom are staff living quarters. 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. Cabinets in communal areas containing cleaning supplies and other items that could pose a risk were observed locked. LPA observed some laundry and cleaning chemicals in the laundry area and garage which were not readily accessible to residents in care, but LPA advised, and Licensee/Administrator agreed to place the observed chemicals and laundry detergents in the cabinet above the washer and dryer and install a lock on the cabinet which will remain locked. Facility has at least two days of perishable foods and a supply of non-perishable foods, which LPA advised Licensee/Administrator to increase to sufficiently sustain all residents in care for a week if needed. Medications were centrally stored and locked. There is outdoor space for activities. LPA observed books, and a couple games and puzzles for client activities. Licensee/Administrator informed LPA that activities change according to the needs and wants of the residents in care. Currently, those involve individualized exercises, knitting, and reading. Facility purchases a new charged fire extinguisher each year, with the most recent one purchased June 2024. 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: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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: AVALON CARE HOME II	FACILITY NUMBER: 486803392
	VISIT DATE: 06/27/2024

NARRATIVE

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Continued from LIC 809...

Facility conducts regular quarterly disaster drills, and the most recent drill was conducted April 2024. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and a back-up generator. LPA advised Licensee/Administrator to increase the facility's emergency water supply to sustain all the residents in care for one week if needed. LPA reviewed facility's emergency disaster plan last updated 11/2020.

At approximately 10:30 AM, three (3) staff files and four (4) resident files were reviewed. All staff files reviewed have the required CPR and First Aid training certificates, as well as all required initial and annual training hours. LPA observed 1 of 3 staff do not have the required LIC501 - Job application. LPA observed all the remaining required documentation in 3 of 3 staff files reviewed. LPA reviewed 4 of 4 resident files and observed 1 of 4 resident files missing proof of negative TB results. LPA observed that 4 of 4 client files had all the remaining required documentation per regulation. Licensee/Administrator states residents' families coordinate their medical and dental appointments as needed and provide their own transportation to and from these visits. LPA reviewed medications and medication records which are maintained in compliance with regulation. Facility does not maintain P&I monies for residents and CCLD has a signed Affidavit (LIC400) on file.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/27/2024:

- LIC 308 Designation of Facility Responsibility (1 person per form)
- LIC 500 Personnel Report
- Copy of Liability Insurance
- LIC 9020 Facility Register of Client/Residents
- LIC 610E Emergency Disaster Plan (updated)

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, may result in a civil penalty assessment.

Exit interview conducted with Licensee whose signature on this document confirms receipt. This report was reviewed with Licensee and Appeal Rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/02/2024 02:12 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/01/2024 03:43 PM

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: AVALON CARE HOME II	FACILITY NUMBER: 486803392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 resident records reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2024
	Plan of Correction
1 2 3 4	***Amended to add POC language due to technical difficulties on 6/27/2024. Licensee/Administrator agrees to submit proof of negatoive TB results to CCLD by POC due date, 7/8/2024.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

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