486803786-3-4-2022-21-AS-ACAA-CC82TD-20220304164035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803786
Report Date: 03/03/2022
Date Signed: 03/04/2022 04:42:02 PM

Document Has Been Signed on 03/04/2022 04:42 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:	ISLES ASSISTED LIVING FACILITY, THE		FACILITY NUMBER:	486803786
ADMINISTRATOR:	EFE, ELENA		FACILITY TYPE:	740
ADDRESS:	129 PACER DR		TELEPHONE:	(707) 254-5444
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Marilou Barrola and Joy Villa, caregivers		TIME COMPLETED:	12:25 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) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, care staff Iverette "Joy" Villa, Marilou Barrola and toured the facility. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. This facility is licensed for a total of 6 non ambulatory residents, there are currently 5 residents in care, none receiving Hospice services. LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices present: entry procedures, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility staff were observed wearing no mask, LPA requested staff to wear mask and follow Covid procedures and Mitigation plan at all times. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan will be reviewed. Caregivers have completed PPE training but have not been N-95 Fit tested. In addition, facility was found to be clean at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged, but last serviced 2/16/2021. During today's inspection staff S1 had the proper fingerprint clearance but was not properly associated to this facility as required Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
	VISIT DATE: 03/03/2022

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The facility Administrator has changed and the facility has not submitted paperwork to Community Care Licensing (CCL) for the change. It was also reported to CCL, there has been facility ownership changes and LPA previously called and left a message for Suzzette Tawzler, that a New License may be required and an Application must be submitted immediately if there is a change of Ownership.
Licensee Suzette Tawzler was not present during the inspection and spoke with LPA by phone. Licensee gave care staff approval to sign licensing reports.

A civil penalty for $100.00 is issued during todays visit, for facility failure to Associate staff S1 to this facility prior to working as required.

Facility staff to get N95 fit tested
Send in updated LIC500 Personnel Report
Send in LIC308 Designation of Responsability

See LIC809-D for:
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights and report will be emailed today to facility, due to technical issues..

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2022 04:42 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: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(d)

Reporting Requirements

(d) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in failing to send in and process the change of Administrator with CCL department as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2022
	Plan of Correction
1 2 3 4	Facility to send in complete paperwork for change of Administrator to CCL Attention LPA Araceli Canela. POC due date 3/25/2022

Type B

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 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays inspection and review of The Guardian], the licensee did not comply with the section cited above in 1 out of 2 staff did not have the proper fingerprint transfer association to this facility prior to working/providing care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2022
	Plan of Correction
1 2 3 4	Facility agrees to submit the required paperwork to CCL to associate staff S1. Facility to send in written plan they understand regulation and how they will ensure future compliance. POC due date 3/4/2022

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2022 04:42 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: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(d)

Admiistrator - Qualifications and Duties

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. 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, facility failed to ensure 2 out of 2 facility staff wear face mask coverings, while in this facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2022
	Plan of Correction
1 2 3 4	Facility to send in written plan on how they will ensure all staff are wearing mouth covering mask while working in this facility. Facility to providerd training to staff and send staff sign in sheet as proof of training. POC due date 3/8/2022 attention LPA Araceli Canela

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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