486803786-3-23-2023-21-AS-ACAA-CQ825X-20230323170616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803786
Report Date: 03/23/2023
Date Signed: 03/23/2023 05:06:24 PM

Document Has Been Signed on 03/23/2023 05:06 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: 6	DATE:	03/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Suzette Tawzer		TIME COMPLETED:	05:04 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 an Annual Required 1 Year inspection and met with Administrator, Suzette Tawzar. Upon arrival, LPA observed that staff continue to wear masks per current guidance. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms measured at 112 and 117 degrees F which is within the required allowed regulation range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Fire extinguisher were last inspected March 3, 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alarms to alert staff, if a door is opened. Three staff files and 3 resident files were reviewed. Staff have required First Aid and CPR certificates but lack the required Health screenings and required staff training. Administrator Certificate for, Suzette Tawzer expires 12/27/2023. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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: 03/23/2023

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Continued from LIC809

One of six residents did not have a fully signed pre-appraisal on file or completed/signed Admission Agreement. Per conversation with Administrator, resident, R1s POA was returning to the facility to complete.

LPA discussed with Administrator, that the left side yard gate is not opening properly and getting stuck, gate is also not self closing and latching as required and needs to be repaired and corrected. In addition LPA went over several areas (8) the backyard wooded deck that are loose, broken and not firm and will be required to be correct or replace.

Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit updates of the following documents by 4/21/2023:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
LIC9020 Register of Residents
LIC308 Designation of Responsibility
Infection Control Plan (If changes)
Liability Insurance
Copy of current Lease Agreement
current facility sketch

LPA was unable to review medication and 3 additional resident files and will return at a later date to complete annual inspection.

No deficiencies cited at this time, LPA will return and issue citations warranted.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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