486804008-9-12-2023-21-AS-DTOA-CVM29S-20230912171224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804008
Report Date: 09/12/2023
Date Signed: 09/12/2023 05:12:33 PM

Document Has Been Signed on 09/12/2023 05:12 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:	ALF SANCTUARY ADULT RESIDENTIAL CARE		FACILITY NUMBER:	486804008
ADMINISTRATOR:	MARIA BUNA		FACILITY TYPE:	740
ADDRESS:	521 SARAH WAY		TELEPHONE:	(559) 303-7020
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 4	DATE:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Maria Buna, Administrator		TIME COMPLETED:	05:30 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	9/12/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Staff, Rayna Yu. Administrator, Maria Buna was contacted and arrived later in the visit. The facility is licensed for 6 non-ambulatory and 1 bedridden resident and a hospice waiver for 2. The facility currently provides care for 4 residents, one of which is receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia all of which were found to be functioning. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/22/2021 and is in need of inspection. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Facility also follows appropriate dietary protocol for resident in care. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured under restroom sinks and storage cabinet in the backyard. Residents were observed engaging in discussion with staff and one another, resting or visited by family. Residents appear to have a positive relationship with staff based on LPA observations. There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications located in a designated cabinet in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found all resident records including physician's report and needs & service plans updated. Lastly, facility conducts and records emergency disaster drill on a quarterly basis. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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: ALF SANCTUARY ADULT RESIDENTIAL CARE	FACILITY NUMBER: 486804008
	VISIT DATE: 09/12/2023

NARRATIVE

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LPA toured the backyard and found two emergency exits located on the sides of the home to be unobstructed. LPA observed separate shed located in the backyard that the facility staff utilize for overnight sleeping during shift changes. Upon LPA interview, staff confirmed using the quarters for overnight sleeping into the following morning shifts. The facility does not have an updated fire clearance or facility sketch approving the use of the shed for living and staff sleeping quarters. Suisun City Fire Marshall, Jose Colin was contacted and arrived at the facility to make additional observations of the staff living quarters. LPA and Fire Marshall both concluded observations and determined that the facility will require a fire clearance and facility sketch. Staff quarters are to be immediately vacated. Fire Marshall will be notifying code enforcement.
**Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
LPA requested the following documents be sent to CCL by COB 10/12/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2023 05:12 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: ALF SANCTUARY ADULT RESIDENTIAL CARE	FACILITY NUMBER: 486804008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation LPA found 2 out of 2 fire exitinguishers in need of inspection. In addition, based on observation, LPA and Suisun City Fire Marshall found a storage building located in the backyard used as a staff sleeping or resting quarters. LPA interview with staff and Administrator confirming staff utilizing sleeping area overnight. Facility does not have a granted fire clearance which poses an immediate health, safety or personal rights risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to ensure staff are not using the quarters located in the backyard shed for sleeping/residing unless fire clearance is granted. In addition, Licensee is to submit a plan of action determining the use of the shed moving forward. If determined to use as sleeping/living quarters, Licensee to submit LIC200 form and updated facility sketch requesting for an updated fire inspection. Documents or any additional plan of action to be submitted to CCLD by POC date 9/13/2023.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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