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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803688
Report Date: 09/12/2023
Date Signed: 09/12/2023 12:51:35 PM


Document Has Been Signed on 09/12/2023 12:51 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SOLANO QUALITY HOME CAREFACILITY NUMBER:
486803688
ADMINISTRATOR:PRAKASH, SNEH LATAFACILITY TYPE:
740
ADDRESS:266 DE SOTO DRIVETELEPHONE:
(707) 386-3600
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 3DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jainendra Prasad, CaregiverTIME COMPLETED:
01:20 PM
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At approximately 09:00AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Member, Jainendra Prasad. Facility has an approved fire clearance for 6 non-ambulatory residents total capacity of 6 residents. Administrator, Sneh Lata Prakash, is out of town, LPA spoke with her via phone.

LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to residents. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Mattress pads were in place or available for resident use. Medication was centrally stored and secure.

LPA reviewed 3 of 3 resident records, which were complete. LPA reviewed a sample of staff records LPA reviewed 2 of 3 requested. Two of staff files were incomplete and Administrator file missing from the facility. Administrator's Certificate (6034507740) has expired as of 4/23/2023. Administrator stated that she has renewed certificate and waiting for delivery.

LPA and Administrator discussed facility's emergency and evacuation plan. The facility's last fire and evacuation drill will be conducted 01/5/2023. Facility's fire extinguishers were last inspected January 12, 2023. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.


Continued on LIC809C.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 09/12/2023 12:51 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SOLANO QUALITY HOME CARE
FACILITY NUMBER: 486803688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above having incomplete staff files and Administrator file missing from the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator will read, get an understanding of the regulation and send self certification to the department by the POC date. The Administrator will ensure all staff have health screenings and TB tests as stated in the Personnel Requirements Sections of Title 22. Files to be complete and maintained at the facility by POC date. Administrator will send photos of completed file for LPA's review no later than the POC date.
Type B
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a bedridden resident without being fire cleared which poses a potential health and safety risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Administrator will request a bedridden fire clearance by submitting a new LIC200 along with updated facility sketch indicating the location of bedridden room to the Department by POC date. The Department will request the fire department to conduct an inspection for bedridden clearance upon receipt of the LIC200 and facility sketch.

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: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


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: SOLANO QUALITY HOME CARE
FACILITY NUMBER: 486803688
VISIT DATE: 09/12/2023
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Continue from LIC809

During the tour LPA observed the following deficiencies:
  • Staff files are incomplete and missing from the facility.
  • No fire clearance for bedridden resident.


LPA conducted staff interviews, residents have dementia.

LPA requested the following documents to update facility file:
· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Health Screening Report for Administrator (LIC 503)
· Updated Personnel Report (LIC 500)
· Updated Liability Insurance
  • Infection Control Plan
· Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Wednesday 09/20/2023

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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