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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804080
Report Date: 08/14/2023
Date Signed: 08/14/2023 02:19:18 PM

Document Has Been Signed on 08/14/2023 02:19 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:DANLE'S CARE HOME IIIFACILITY NUMBER:
486804080
ADMINISTRATOR:DANLE, SINNINFACILITY TYPE:
735
ADDRESS:811 WHITE WING LANETELEPHONE:
(707) 759-2028
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 4DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Singa Danle (Staff)TIME COMPLETED:
02:33 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct an Annual Required inspection and met with co-Administrator Robert Schweitzer. Staff Singa Danle arrived later. Licensee was not available to come to the facility, but was available by phone and gave authorization to staff to sign the report. Clients were attending to Day Program.

LPAs/staff initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 106.7 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet. Medications are centrally stored in locked cabinet and medication records were reviewed. Fire extinguishers were last inspected October 2022. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 6/30/23. Facility does have a current activity calendar and menu. Required postings were observed. First aid kit was fully stocked.

At approximate 9:30am LPAs/staff observed bathroom located upstairs between room #3 and 4 is under construction with unfinished sink, exposed ceiling, unstable partitions. Also, room #3 had laminate over carpet. Per staff, the repairs started late June, 2023. However, LPAs reviewed incident report logs for this facility, and it was determined that incident report were not submitted to CCL. There were no construction tools observed in the construction area.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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: DANLE'S CARE HOME III
FACILITY NUMBER: 486804080
VISIT DATE: 08/14/2023
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Continued from LIC809...

Per staff, the city did not issue a permit because the bathroom is just being updated, but they could not provide a specific date when the work will be completed. LPAs discussed with staff the importance of resident's safety throughout the construction project. Staff assured LPAs that the construction staff and facility staff will make sure that safety precautions regarding tools, toxins and exposure to safety hazards will addressed daily and while construction crews are on site and after the daily construction work is completed.

During today's visit LPAs learned about client (C1) has been hospitalized since Wednesday (8/9/23). However, staff stated that they did submit an incident report to placement agency, but did not notify CCL about C1's hospitalization as stated per regulation.

At approximate 10:00am LPAs/staff observed expired food located in the facility's pantry as follow: box of cornbread (7/7/23), box of mac & cheese (7/2023), green beans can (10/2022), 2 tomato sauce can (5/22/23) and tomato salsa (4/4/21).

At 10:30am LPAs conducted a file review of four client and three staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Sinnin Danle 6010244735 expires 2/24/24. Cash resources and documentation were reviewed. However, cash and facility ledgers for client (C2) did not match (see LIC 9102 TV).

Licensee provided updates of the following documents: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond and LIC400 (cash affidavit for clients).
Deficiencies 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. Exit interview conducted with staff and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/14/2023 02:19 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/14/2023 at 01:23 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: DANLE'S CARE HOME III
FACILITY NUMBER: 486804080

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on observation, interview with facility staff, the licensee did not comply with the section cited above in one out of three bathrooms used by clients in car which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Licensee agreed to submit a written plan ensuring compliance with Title 22 regulation including completion date of the construction by POC due date
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with facility staff, the licensee did not comply with the section cited above as evidenced by LPAs observersation of expired food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Licensee agreed to ensure the food in the pantry is checked and discarded if needed. Develop a written plan of how the food supply will be checked and inspected on a regular basis to ensure the food is of good quality and not expired by POC due date.
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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/14/2023 02:19 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/14/2023 at 01:23 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: DANLE'S CARE HOME III
FACILITY NUMBER: 486804080

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above and did not notify CCL about client's (C1) hospitalization and bathroom's used by clients remodel process, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee agreed to review the requirements of 80061 and submit a written, signed declaration to CCL which attests to the facility's commitment to follow the requirements going forward. To be submitted to CCL by POC date in order to clear the deficiency.
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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
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