486803781-12-19-2024-21-AS-JFLO-DC4VN5-20241219153431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803781
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:34:49 PM

Document Has Been Signed on 12/19/2024 03:34 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:	ADELAIDE HOME II		FACILITY NUMBER:	486803781
ADMINISTRATOR/ DIRECTOR:	JASMINE ALISCAD		FACILITY TYPE:	740
ADDRESS:	1155 MAHOGANY CT		TELEPHONE:	(707) 207-3941
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Jasmine Aliscad, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 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	At approximately 11:00 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and were greeted by Jasmine Aliscad, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Residents 2 (R2), Resident 3 (R3) and Resident 4 (R4) were present during inspection and LPAs were informed that Resident 1 (R1) was away at their day program. Facility has a Dementia Care Plan, is approved for all non-ambulatory residents, and is vendorized with North Bay Regional Center (NBRC). At approximately 11:45 AM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. However, LPAs observed the key used to unlock said cabinets hanging on a hook in the kitchen where accessible to residents in care, (see LIC809D). Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency Food and water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed 1 locked shed in the backyard which LPAs inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, and an emergency generator. LPAs observed an activity schedule and were informed that the residents play bingo, go bowling, watch movies, and engage in sensory activities. Facility also hosts holiday parties for the residents and throws a large Halloween, Thanksgiving, Christmas, and 4th of July party in a central location where all five (5) care homes attend. Facility has internet access and provides a designated internet access device for resident use. Facility has a telephone which was tested during inspection. Continued on LIC809-C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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: ADELAIDE HOME II	FACILITY NUMBER: 486803781
	VISIT DATE: 12/19/2024

NARRATIVE

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Continued from LIC809C...

Facility's fire extinguisher was observed charged and was last serviced 10/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system was tested and all fire doors closed automatically. Facility conducts monthly disaster drills, and the most recent drill was conducted 12/2024. LPAs observed the facility's infection control plan, first aid kit, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 1/2024.

At approximately 12:45 PM, LPAs conducted file review. Four (4) staff files and four (4) resident files were reviewed. All staff files reviewed have all of the required paperwork including the required CPR and First Aid training certificates and documentation of all required initial and annual training hours. Four (4) of four (4) resident files reviewed contained all the required documentation per regulation.

Administrator states they coordinate residents' medical and dental appointments and transportation to and from visits. Medications and P&I were reviewed and observed managed and maintained within regulation.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)
LIC610D Emergency Disaster Plan (updated)
Proof of Liability Insurance (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 Administrator and Appeal rights were given. Signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/19/2024 03:34 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: ADELAIDE HOME II	FACILITY NUMBER: 486803781
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that the key used to secure cabinets containing items which could pose a risk to residents in care if readily available to them was inaccessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2024
	Plan of Correction
1 2 3 4	Administrator removed and secured the key away from residents immediately. Administrator conveys an understanding that the key shall remain inaccessible to residents in care at all times. POC cleared during inspection.

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.

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC809 (FAS) - (06/04)

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