486803956-1-27-2023-21-AS-KWAS-CNH3HB-20230127171541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803956
Report Date: 01/27/2023
Date Signed: 01/27/2023 05:18:29 PM

Document Has Been Signed on 01/27/2023 05:18 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:	CONNECTED LIVING VACAVILLE		FACILITY NUMBER:	486803956
ADMINISTRATOR:	TRAIL, SARA		FACILITY TYPE:	735
ADDRESS:	82 MANZANITA DRIVE		TELEPHONE:	(925) 826-6830
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY: 3		CENSUS: 3	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:43 PM
MET WITH:	Cedric Tanner		TIME COMPLETED:	05:29 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), Katrina Walters arrived unannounced to conduct a Required 1 Year inspection, and met with Facility Director, Cedric Tanner, the Administrator, Sara Trail was not available for today's visit. The inspection is focused on the Infection Control procedures and practices of the facility. The facility submitted an infection control plan to community care licensing, which was approved. There are currently three (3) clients in care. Facility has an approved fire clearance three (3) non-ambulatory clients. LPA observed that there was a screening station at the entrance of the facility with hand sanitizer, thermometer and disposable mask. Clients are observed for any changes. Facility was found to be clean, orderly, and at a comfortable temperature. Continued on 809 C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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: CONNECTED LIVING VACAVILLE	FACILITY NUMBER: 486803956
	VISIT DATE: 01/27/2023

NARRATIVE

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Continued from 809

All exits were observed free from obstruction. Carbon Monoxide and Smoke detectors were tested and appeared to be operational. Toxins are stored inaccessible and in locked a pantry. The facility has a sufficient supply of personal protective equipment (PPE). All postings were up and visible to all as required.

LPA observed bottles of medication in resident R1's bedroom. (pictures taken) R1's bedroom door was unlocked and accessible to other residents. LPA was unable to determine the physician's guidance in managing R1's medication, due to the facility not keeping the residents Physician Report on the facility premises. LPA learned that both staff and resident's documentation, including their P & I records, medication records, physician reports and admission agreements were being stored at another facility. The Licensee was unable to bring the resident and records in an appropriate time.

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.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2023 05:18 PM - It Cannot Be Edited

Created By: Katrina Walters On 01/27/2023 at 04:16 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CONNECTED LIVING VACAVILLE	FACILITY NUMBER: 486803956
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(d)

80070 Client Records d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, observation and record review Licensee did not ensure that clients records are available at the facility site which poses a potential risk to clients in care.
	POC Due Date: 01/30/2023
	Plan of Correction
1 2 3 4	Administrator will self-certify that they have reviewed regulation 80070(d)

Type B

Section Cited

CCR

80066(a)

80066 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews,observations, and record review did not ensure that personnel records are available at the facility site which poses a potential risk.
	POC Due Date: 01/30/2023
	Plan of Correction
1 2 3 4	Administrator will self-certify that they have reviewed regulation 80070(d)

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

LICENSING EVALUATOR NAME:

Katrina Walters

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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