486803645-10-15-2021-21-AS-CFGS-C7U3TK-20211015183204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 10/15/2021
Date Signed: 10/15/2021 06:32:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	PACIFICA SENIOR LIVING VACAVILLE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	LEE-ALLMOND, MELODY		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 65	DATE:	10/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Melody Lee-Allmond - Executive Director		TIME COMPLETED:	02:30 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) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Melody Lee-Almond Executive Director & Mae Mora – Resident Services Director. Facility has 65 residents with 13 residents under Hospice care at this time. Facility offers activities during the day. During facility tour on 10/15/2021 with staff Donaldo Antiado - Maintenance Director and Mae Mora – Resident Services Director, facility was found to be at a comfortable temperature. Sample of resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Sample test of Smoke Detector & Carbon monoxide detector were found to be operational during the visit. Fire Extinguisher was found to be last charged on 04/2021 at the time of the visit. Annual fire/sprinkle inspection occurred on 10/13/2021. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a list of dietary needs for residents in care in addition to a dietary binder in the houses. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Facility understands that hot water temperatures must measure within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Facility has posters that placed at facility. At this time facility is planning to have at entrance a table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility have enough PPE supplies stored in the facility storage. Facility has admitted new residents since COVID-19. Continued LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE	FACILITY NUMBER: 486803645
	VISIT DATE: 10/15/2021

NARRATIVE

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Residents medications are stored and locked in a locked medication room in each house. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are sometimes able to wear masks when going on outings. All staff had masks on during this visit.

In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available video and telephone calls when contacting with family members and others. Staff had all PPE training required on file and facility is working towards obtaining N-95 fit testing.

In addition, LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).

No deficiencies cited during this inspection.

Department is requesting the following updated documents to be submitted to CCLD by 10/22/2021:

LIC 309 Administrative Organization
LIC 308 Designated Administrator
LIC 610 Emergency Disaster Plan
LIC 610E Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC809 (FAS) - (06/04)

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