486803786-1-26-2024-21-AS-ACAA-CZUTHY-20240126134527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803786
Report Date: 01/22/2024
Date Signed: 01/26/2024 01:46:24 PM

Document Has Been Signed on 01/26/2024 01:46 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:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Suzette Tawzer, Administrator		TIME COMPLETED:	05:27 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 care staff, Reinalee Sanchez and Marilou Barrola, Administrator, Suzette Tawzer arrived a few minutes later. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. All auditory door alarms were operational, resident rooms have small hand held bells for residents to use to alert staff. Residents rooms were furnished per regulation. Water temperature in bathrooms measured at 115 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. Three staff files and 6 resident files were reviewed. Staff have required First Aid and CPR certificates, that expire 2/2024 and 8/2024. Staff have the required annual training in file, including dementia training. All three staff present are fingerprint cleared and associated to this facility. Administrator Certificate for, Suzette Tawzer expired 12/27/2023 but Administrator has already submitted paperwork to renew the certificate. LPA will review facility file application for possible current changes in organization that may require a new application. LPA will notify Administrator once reviewed. 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: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
	VISIT DATE: 01/22/2024

NARRATIVE

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Continued from LIC809

Two of six resident files did not have a current medical assessment in file and current resident appraisal on file.

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

The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided.

Licensee/Administrator to submit updates of the following documents by 2/21/2024:
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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/26/2024 01:46 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: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays file review with Administrator, the licensee did not comply with the section cited above in 2 out of 6 resident did not have a current medical assessment in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Facility to send in written plan on how they will stay in compliance. Proof of medical assessment for resident R1 and R2 to be submitted to LPA A Canela, by POC date 2/16/2024

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays file review with Administrator, the licensee did not comply with the section cited above in above in 2 out of 6 resident did not have current resident appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Facility to send in written plan on how they will stay in compliance. Proof of current resident appraisals be submitted to LPA A Canela, by POC date 2/16/2024

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: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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