486803949-9-2-2021-21-AS-KWAS-C6H4R8-20210902191933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803949
Report Date: 09/02/2021
Date Signed: 09/02/2021 08:08:21 PM

Document Has Been Signed on 09/02/2021 08:08 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	ST JOSEPH CARE HOME		FACILITY NUMBER:	486803949
ADMINISTRATOR:	LIM, RAQUEL VICTORIA		FACILITY TYPE:	740
ADDRESS:	829 HARRIER DRIVE		TELEPHONE:	(510) 809-6912
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 5	DATE:	09/02/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Jocelyn Bautista, Staff		TIME COMPLETED:	07:30 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) Walters arrived announced to conduct a post licensing visit. LPA was welcomed by Jocelyn Bautista - Facility Staff; Administrator, Victoria Lim was available by phone for today's visit. There were a total of 5 residents in care at the time of inspection. LPA had conducted a pre-licensing inspection on 04/23/2021 and 05/07/2021, and also reviewed all Covid 19 pandemic precautions in place at the facility with the Administrator. Administrator corrected all deficiencies observed during those inspections. LPA toured the facility on 9/2/2021 at 1:45 PM with Facility Staff, Jocelyn Bautista. LPA made the following observations: All toxins and medications were locked up and inaccessible to residents in care. Food supply, perishable and nonperishable were observed to be sufficient. Facility common areas were observed to have sufficient lighting throughout the facility. Facility had emergency supplies to meet requirement for the 72 hour shelter in place. Postings noted to be current and in compliance with regulations. At 1:57 PM LPA and staff observed rodent droppings in the facility hallway closet. (Pictures taken). Administrator contacted a pest control company, while LPA was at the facility. LPA also learned that 3 of 3 staff present at the facility were not associated to the facility and were unable to provide proof of fingerprint clearance. LPA explained to Administrator that all staff are to be fingerprint cleared and associated, prior to working in the facility. Continued on to LIC809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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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Document Has Been Signed on 09/02/2021 08:08 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST JOSEPH CARE HOME	FACILITY NUMBER: 486803949
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87355(e)(3)

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: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During today's inspection 3 of 3 Staff were not associated to this facility. S1 has a fingerprint Exemption clearance and facility did not receive approval prior to staff working. This is an immediate risk to the Health and safety of residents in care.
	POC Due Date: 09/08/2021
	Plan of Correction
1 2 3 4	Administrator send in written plan facility understands all staff must be associated and/or fingerprinted to facility prior to working and how facility will meet regulation.

Request Denied

Type A

Section Cited

CCR

80087(a)

80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation during inspection rodents droppings were located in the hallway of the facility which poses an immediate risk to the health & safety of residents in care.
	POC Due Date: 09/07/2021
	Plan of Correction
1 2 3 4	Licensee contacted pest control company. Licensee agrees to submit proof of service to CCL by POC due date 9/7/2021.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST JOSEPH CARE HOME	FACILITY NUMBER: 486803949
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87615(a)(1)

87615(a)(1)Prohibited Health Conditions. Residents with prohibited conditions shall not be admitted or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews and record review, the licensee did not comply with the section cited above. Facility retained R1 who had unstageable pressure injury. Although the injury is not yet staged, it appears to be more than stage 2. Which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2021
	Plan of Correction
1 2 3 4	Licensee to ensure all residents are appropriate for licensed level of care; Licensee will not retain or admit residents who have prohibited health conditions without prior CCL approval. Licensee to update policy and procedures regarding routinely assessing residents and observing changes of conditions and conduct an in-service training. If Licensee wishes to retain, R1, they will need an exception.

Type A

Section Cited

CCR

80075(k)(5)

80075(k)(5) Health Related Services - Each client's medication shall be stored in its originally received container. This requirement was not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview conducted, Licensee did not ensure medications were not pre-poured and out of original container. Resident R1's medication was poured 12 days in advance. This is an immediate health and safety risk to clients in care.
	POC Due Date: 09/08/2021
	Plan of Correction
1 2 3 4	Licensee will review regulation 80075(k)(5). Licensee to submit documentation of training, and include date, time, duration, topic, staff names & signatures to CCL attention LPA Walters by POC due date 09/8/2021.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/02/2021 08:08 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST JOSEPH CARE HOME	FACILITY NUMBER: 486803949
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87623(b)(2)

87623(b)(2) Indwelling Urinary catheter..the bag may be emptied by facility staff who receive instruction from skilled professional..with written documentation by the professional stating what and who were trained...and that a professional reviews staff performance...at least annually. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above for R1. Facility staff emptied R2's catheter is not a skilled professional and does not posess training to assist with catheter care. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2021
	Plan of Correction
1 2 3 4	Licensee to submit to CCL by POC date 09/7/2021 documentation of staff training as required by 87623(b)(2) in order to clear the deficiency. Training to be conducted by a skilled professional per regulation.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ST JOSEPH CARE HOME	FACILITY NUMBER: 486803949
	VISIT DATE: 09/02/2021

NARRATIVE

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LPA also learned through interview and record review that resident R1 has a catheter, which requires staff to assist with emptying. Staff confirmed they empty R1's catheter bag. LPA explained that catheter bags are to be emptied by skilled professional or trained staff. LPA found no catheter training for staff. LPA conducted a review of 5 resident files. Facility understands that they're to have resident's Physician Reports and Pre-assessments completed prior to residents moving in. Through record review, LPA learned that resident R1 has a pressure wound. Per staff the wound has not yet been staged. The wound appeared to be more than a stage 2. (pictures on file).

At 6:00 PM LPA conducted a review of residents medication and observed that facility staff pre-poured 12 days of medication for resident R2.
LPA Walters is requesting the following by 9/7/21:

Administrator to send proof that all staff are fingerprint cleared and associated to the facility.
Administrator send in written plan facility understands all staff must be associated and/or fingerprinted to facility prior to working and how facility will meet regulation.
Administrator to provide a copy of all resident's Physician's reports and Needs and Service Appraisals.
Administrator to provide proof of service that the facility has received pest control services.
Administrator to contact physician to have wound stage
Update policy and procedures
Staff training's
Licensee to submit documentation of training, and include date, time, duration, topic, staff names & signatures to CCL
LPA is also requesting that Administrator contacts R2's physician and notify them of their condition. Administrator to notify LPA 9/3/21.

Facility was issued a Civil penalty in the amount of $1500.00 for the following S1 S2 and S3 who was not associated and did not have Fingerprint transfer by the Department.The following deficiencies were observed (see LIC 809-D) 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, copy of this report and appeal of rights provided by email.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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