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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804007
Report Date: 11/01/2024
Date Signed: 11/01/2024 06:24:30 PM

Document Has Been Signed on 11/01/2024 06:24 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:INFINITI CARE HOME #1FACILITY NUMBER:
486804007
ADMINISTRATOR/
DIRECTOR:		FROLIAN DEVERAFACILITY TYPE:
735
ADDRESS:607 TRAVIS BLVDTELEPHONE:
(707) 771-1516
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Froilan Devera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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At approximately 2:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Froilan Devera, Administrator. Licensee, Carl Resurreccioa arrived at approximately 2:50 PM, and Licensee, Julie Martuscello arrived at approximately 3:45 PM. Facility is an Adult Residential Facility with four (4) ambulatory clients in care and all were present during visit. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 3:00 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed the face of two drawers in bathroom #1 broken off exposing several nails which poses a risk to clients in care, (see pictures and LIC809D). LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available to clients in care. Additionally, LPA observed used towels and wash clothes present in both communal bathrooms and in the shower of bathroom #2, (see pictures and LIC809D). Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Bedroom #5 is live-in Staff 1's (S1's) bedroom and was observed unlocked with nail polish remover and at least three (3) instances of medications or vitamins accessible to clients in care, (see pictures and LIC809D). LPA observed over five (5) instances of chemicals or toxins that could pose a risk to clients in care, (see pictures and LIC809D). Facility has at least two days of perishable food and one week of non-perishable foods. However, LPA observed at least five (5) instances of expired food and opened food items in the freezer not labeled with the open date or repackaged properly to ensure food safety, (see pictures and LIC809D). Facility uses magnet locks for some of their cabinets which LPA observed stored next to the wall mounted key holder in the kitchen where it was accessible to clients in care. Administrator and Licensees agreed to ensure that the magnet shall remain inaccessible to clients in care at all times.
Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: INFINITI CARE HOME #1
FACILITY NUMBER: 486804007
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC809...

Medications were centrally stored and locked. There is outdoor space for activities in the backyard. The gate in the backyard was observed with a noncompliant gate lock consisting of a sliding bolt lock. Administrator and Licensee Martuscello were informed that to bring the lock into compliance, they will need to replace the lock with a latch lock, (see pictures and LIC809D). LPA observed an activity schedule, games, and crafting supplies and was informed that each client has their own internet access device. Facility has internet available to clients in care and the phone was tested an operational.

Facility's fire extinguisher was observed charged and was last serviced 4/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducted its most recent emergency disaster drill 5/2024. LPA informed Administrator and Licensee that moving forward these drills shall be conducted on a quarterly basis in order to be in compliance. LPA observed facility's infection control plan and emergency disaster plan which was last updated 5/2024. LPA observed a supply of PPE, emergency supplies, a first aid kit, and a lantern for emergency preparedness. Administrator states the facility does not have a backup generator.

*LPA will return at a later date to complete staff and client file review, as well as medication and P&I inspections.

Administrator to submit the following documentation to CCL within 30 days of today's visit:

LIC500 - Staff Roster (Updated)
Facility's New Lease Agreement

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/01/2024 06:24 PM - It Cannot Be Edited


Created By: Julie Florio On 11/01/2024 at 05:33 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: INFINITI CARE HOME #1
FACILITY NUMBER: 486804007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in over five (5) instances of chemicals or toxins that could pose a risk to clients were accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Administrator to submit a self-certification ensuring no items which pose a risk to clients in care will be accessible to clients in care to CCL by POC due date 11/4/2024.
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in at least five (5) instances of expired food found and opened food items in the freezer found not labeled with the open date or repackaged properly to ensure food safety which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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3
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Administrator to submit a self-certification stating that all food items have been inspected and the facility will ensure no items of expired food, unlabeled opened food, or improperly stored food items will occur moving forward to CCL by POC due date 11/4/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/01/2024 06:24 PM - It Cannot Be Edited


Created By: Julie Florio On 11/01/2024 at 05:33 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: INFINITI CARE HOME #1
FACILITY NUMBER: 486804007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in over 3 instances of medication an vitamins observed in S1's unlocked bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Administrator to submit a self-certification stating they will ensure all medications, vitamins, and supplements remain inaccessible to clients in care moving forward to CCL by POC due date 11/4/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/01/2024 06:24 PM - It Cannot Be Edited


Created By: Julie Florio On 11/01/2024 at 05:33 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: INFINITI CARE HOME #1
FACILITY NUMBER: 486804007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 instances where LPA observed the face of two drawers in bathroom #1 broken off exposing several nails, and the gate in the backyard with a sliding bolt lock, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Administrator to submit photo proof that the bathroom drawers have been repaired to CCL by POC Due date 11/8/2024. Additionally, Administrator to submit photo proof that the backyard gate lock has been replaced with a complaint latch lock to CCL by POC due date 11/29/2024.
Type B
Section Cited
CCR
85088(c)(4)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (B) The use of common towels and washcloths shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 instances of used towels and washcloths observed hanging in the communal bathrooms and a shower, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Administrator to self certify that facility will ensure no towels or washcloths will be stored in communal bathrooms moving forward to CCL by POC due date 11/8/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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