486803666-8-16-2022-21-AS-KWAS-CHCQA8-20220816115932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803666
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:01:11 PM

Document Has Been Signed on 08/16/2022 12:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CASA ISABELLA		FACILITY NUMBER:	486803666
ADMINISTRATOR:	VILLEGAS, IMEE C		FACILITY TYPE:	740
ADDRESS:	3060 DUKE CIRCLE		TELEPHONE:	(707) 398-7539
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	6	CENSUS: 5	DATE:	08/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Imee Villegas		TIME COMPLETED:	12:15 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) Katrina Walters arrived unannounced to conduct a Required 1-Year Inspection and met with Administrator, Imee Villegas. The inspection is focused on the Infection Control procedures and practices of this facility. At primary entrance LPA observed temperature logs and visitor sign-in sheet. N-95 mask, disposable gowns, and hand sanitizer were available for visitors. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan and Infection Control Plan was submitted and available for review. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Updated infection control guidelines and PINs are sent to the families and responsible parties. Staff have completed Personal Protective Equipment (PPE)/infection control training. Administrator maintains a binder with current COVID-19 protocols and contingency plans. Staff keep inventory of PPE. Inventory of PPE is stored in garage and Staff room. LPA confirmed facility has at least a 30-day supply of PPE and incontinence products. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with emergency procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored in a locked. All staff and residents are vaccinated and boosted. Continued on LIC 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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: CASA ISABELLA	FACILITY NUMBER: 486803666
	VISIT DATE: 08/16/2022

NARRATIVE

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Continued from 809

LPA observed two video surveillance camera's located in bedroom 1 and 3. Video's were pointed toward resident's beds. Video's have audio. Administrator explained that the camera's were approved by the resident's families and only used at night. LPA explained that camera's cannot be used to supervise care. Video Surveillance violates resident's personal rights. Administrator will inform family of video surveillance guidance and submit an exception request to licensing.

Regarding the cameras set up in resident's bedrooms, which violates resident's personal rights, the LPA will be citing this violation, Personal rights 80072(a)(1)-see LIC809D.
The following deficiency(s) was/were cited (see LIC809D) 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. Exit interview conducted and appeal of rights provided.

LPA requested updated copies of the following documents: LIC 500, LIC 9020, Liability Insurance, Emergency Disaster Plan, and LIC 308. Exit interview conducted with administrator and a copy of the report provided to the Administrator. No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2022 12:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CASA ISABELLA	FACILITY NUMBER: 486803666
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072

80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and interviews, the licensee did not comply with the section cited above by having two camera's set up ito watch over two clients each in their bedrooms, this is an area that privacy is expected which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/17/2022
	Plan of Correction
1 2 3 4	Administrator will submit an exception request to licensing, along with the families approval.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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