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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803786
Report Date: 03/11/2020
Date Signed: 01/19/2021 04:44:29 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:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:EFE, ELENAFACILITY TYPE:
740
ADDRESS:129 PACER DRTELEPHONE:
(707) 254-4444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
03/11/2020
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Anne Marie RahmTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) A. Canela conducted an unannounced Case Management - Annual Continuation Inspection and met with care staff Anne Marie Rahm and Cynthia Cacatian. Administrator, Suzette Tawzer was not available during the visit. LPA was previously in this facility on 2/21/2020 and began the required 1 year annual inspection, but was unable to complete inspection due to computer issues. This six bed facility serves elderly residents with dementia and is licensed to care for 6 residents on hospice services and who may be bedridden. On today's inspection, and inspection of 2/21/2020, LPA was greeted by two staff who were fingerprint cleared, but facility did not associate them to the facility prior to working as required. LPA informed Administrator of requirement and forms that need to be submitted to Community Care Licensing (CCL) to transfer employees fingerprints to this facility and associate them as required. Administrator explained, she called CCL to transfer employees. LPA once again explained process and provided facility a note, with items needed to complete process. LPA also expressed to administrator her responsibility in understanding Title 22 regulation and that LPA could provide some assistance and go over some of the responsibilities, but administrator should review regulations first.


LPA previously inspected facility on 2/21/2020 and during today's inspection: Facility is clean, in good repair and at a comfortable temperature. Exits doors are equipped with auditory devices, but during 2/21/2020 inspection 7 out of 8 doors had the auditory alarm turned off and not operational. During today's visit 6 of 8 doors did not have an auditory alarm turned on. The facility is required to have working auditory devices to alert staff, as there is resident R3 with Dementia diagnoses and wandering behaviors. Fire Extinguisher located near the kitchen was found to be charged but last service date was 11/16/2018 and requires to be serviced.

Continue report see LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020
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 7
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
VISIT DATE: 03/11/2020
NARRATIVE
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Hot water temperature tested in bathrooms measured between 109.9 and 112 degrees F, which is within Title 22 acceptable regulation of 105 to 120 degrees F . There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods and the refrigerator was clean and food appears to be stored properly. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Staff present state that there are no weapons in the home. There is no swimming pool or accessible bodies of water. Resident's medication centrally stored and facility locks them in a medication closet, but during 2/21/2020 visit LPA observed both staffs bedrooms not locked and there were several medications accessible to residents.

LPA reviewed facility records on 2/21/2020: Administrator Certificate was not available during the visit, last Administrator certificate in file was date 2015 for Suzette Tawzer . Staff have first aid and CPR training expiring 6/13/2020. Staff files for S1 and S2 did not have proof of the required annual training. LPA reviewed 6 resident files & medication record and 2 resident medication were not entered in the centrally stored medication log. 3 out of 6 residents lacked doctors prescription for the use of half bed rails as mobility/postural support.

**Immediate Civil Penalty assessed in the amount of $500.00 for locked door room R3 and left side gate.
**Immediate Civil Penalty assessed in the amount of $1000.00 for facility having S1 and S2 providing care Without a clearance transfer or exemption transfer.

Deficiencies cited 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2020

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

Deficient Practice Statement
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This requirement was not met- As evidenced by: During the inspection of 2/21/2020 and today's visit. The licensee did not have the following two staff, S1 & S2 associated to this facility as required. Licensee was provided form numbers needed on 2/21/2020 to associate staff and LPA once again provided form numbers and items needed to be faxed to associate individuals. This is an immediate risk to the health and safety of residents in care.
POC Due Date: 03/12/2020
Plan of Correction
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LIcensee to send in written plan that they understand regulation requirement, process and paperwork needed to complete process.
Staff provided copies to LPA for S1 & S2 to be associated. Written plan due 3/12/2020 to LPA Araceli Canela by Fax(707)588-5080 or email araceli.canela@dss.ca.gov

**Immediate Civil Penalty assessed in the amount of $1000.00 for facility having S1 and S2 providing care Without a clearance transfer or exemption transfer.
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

Deficient Practice Statement
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This requirement was not met- As evidenced by: During the inspection of 2/21/2020, LPA observed medication and vitamin supplements not locked in staffs room and in the office room not locked. During todays visit LPA observed, oxy clean bottle in staffs bathroom and bottles of Clorox in the unlocked garage. This is an immediate risk to the health and safety of residents in care.
POC Due Date: 03/12/2020
Plan of Correction
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Licensee to send in written plan that they understand regulation an plan to ensure items such as cleaning supplies, medications, vitamins are made inaccessible to residents. Facility to send in statement that all staff have been trained with staff signatures.
Written plan due 3/12/2020 to LPA Araceli Canela by Fax(707)588-5080 or email araceli.canela@dss.ca.gov
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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2020

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

Deficient Practice Statement
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This requirement was not met- As evidenced by: The facility did not have proof an Administrators certificate for S3. This is a potential risk to the health and safety of residents in care.
POC Due Date: 04/03/2020
Plan of Correction
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Facility to send in proof of administrators certificate to LPA by POC due date of 4/3/2020.
Araceli Canela by Fax(707)588-5080 or email araceli.canela@dss.ca.gov
Section Cited
Personnel Requirements - General
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2020

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

Deficient Practice Statement
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This requirement was not met- As evidenced by: The facility did not have proof of the required 20 hour annual training for S1 and S2. Eight of the hours of in-service training per year on the subject of serving residents with dementia. This is a potential risk to the health and Safety of residents in care.
POC Due Date: 03/27/2020
Plan of Correction
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Facility to send in proof of staff required training for S1 and S2 to LPA by POC due date of 3/27/2020.
Araceli Canela by Fax(707)588-5080 or email araceli.canela@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2020

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

Deficient Practice Statement
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This requirement was not met- As evidenced by: The facility did not have a plan for scheduled activities. This is a potential risk to the health and safety of residents in care.
POC Due Date: 03/25/2020
Plan of Correction
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Facility to send in plan of scheduled activities. POC due 3/25/2020 to LPA Araceli Canela by Fax(707)588-5080 or email araceli.canela@dss.ca.gov
Type B
Section Cited
CCR
87465(a)(7)
Incidental Medical and Dental Care Services
(7) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

Deficient Practice Statement
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This requirement was not met- As evidenced by: The facility did not log 2 out of 4 medications for resident R2 in the centrally stored log. This is a potential risk to residents in care.
POC Due Date: 03/25/2020
Plan of Correction
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Facility to send in written plan on how facility will ensure medications are logged in the centrally stored log and proof of staff training regarding this requirement. POC due 3/25/2020 to LPA Araceli Canela by Fax(707)588-5080 or email araceli.canela@dss.ca.gov
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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 7 of 7
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2020

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
Deficient Practice Statement
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This requirement was not met - As evidenced by: During the inspection of 2/21/2020, LPA observed residents room R3 with a screw on the bottom of the sliding door to prevent it from opening and the left side gate, tied up to prevent it from opening. This is an immediate risk to the health and safety of resident in care
POC Due Date: 03/12/2020
Plan of Correction
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LIcensee to send in written statement that they understand regulation and staff training regarding not locking exit doors. Facility removed screw from R3 bedroom and unlocked side gate. **Immediate Civil Penalty assessed in the amount of $500.
POC due date 3/12/2020 attn: Araceli Canela Fax: (707)588-5080 or by email to: araceli.canela@dss.ca.gov
Type A
Section Cited
CCR
87705(j)
87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
Deficient Practice Statement
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This requirement is not met as evidenced by: .*** Based LPA observation during inspection of 2/21/2020, 7 out of 8 doors had the auditory alarm turned off and not operational. During today's visit 3/11/2020, 6 of 8 doors did not have an auditory alarm turned on. The facility is required to have working auditory devices to alert staff, as there is resident R3 with Dementia diagnoses and wandering behaviors. Bedroom sliding doors are left open to allow fresh air and the alarms are turned off, or only sound once when they are first opened and do not alert staff if a resident is exiting. This is an immediate risk to the health and safety of residents in care.
POC Due Date: 03/12/2020
Plan of Correction
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Facility to send in written plan on how facility will ensure all auditory alarms are working and operation to alert staff. Facility to send in written plan to LPA Araceli Canela by 3/12/2020 and proof that staff have been trained and understand requirement.
POC due date 3/12/2020 attn: Araceli Canela Fax: (707)588-5080 or by email to: araceli.canela@dss.ca.gov
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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 2 of 7