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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804110
Report Date: 09/19/2024
Date Signed: 09/20/2024 07:23:23 AM

Document Has Been Signed on 09/20/2024 07:23 AM - 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:ZINA'S CARE HOME IFACILITY NUMBER:
486804110
ADMINISTRATOR/
DIRECTOR:		LEE, ZINA M.FACILITY TYPE:
735
ADDRESS:3000 CHESTNUT CTTELEPHONE:
(707) 434-1117
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Zina Lee, AdministgratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 9/19/2024, Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Inspection of this Adult Residential Facility and was greeted by Staff, Jacqueline Bearden. Administrator, Zina Lee was contacted and arrived during visit. The facility currently provides care for 3 clients, 2 of which were present, leaving for day programs at the beginning of visit and 1 of which was attending day program at the time of visit.

At approximately 9:00 AM LPA toured facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/25/2023. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. Water temperature in faucets accessible to clients was 136.4 degrees F falling out of regulatory range of 105 degrees to 120 degrees F (see LIC 809-D) Administrator turned down during inspection. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food stored in the garage. Food stored in the kitchen refrigerator were stored properly with appropriate labeling and dates. There was a supply of linens, hygiene products and paper products available for clients located in the hallway.

At approximately 9:45 AM LPA conducted a file review for 3 out of 3 clients. Clients' (C1) did not have copy of TB (see LIC 809-D). The Needs & Service Plans for all clients have been updated as of January 2024. At approximately 11:00 AM LPA conducted a sample file review of 3 staff and found all staff to have appropriate training, 1st aid & CPR certification on file. Although 2 staff (S1 & S2) did not have required Health Screening or TB tests (see LIC 809-D). In addition, facility conducts emergency evacuation drills with staff and clients every three months with the last conducted on 6/5/2024.

Continued onto LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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 7
Document Has Been Signed on 09/20/2024 07:23 AM - It Cannot Be Edited


Created By: Shannan Hansen On 09/19/2024 at 12:29 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: ZINA'S CARE HOME I
FACILITY NUMBER: 486804110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 1 out of1 faucets (bathroom) accessible to clients in care to be 136.4 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator adjusted hot water heater during visit, Administator to submit adjusted water temp as of 9/20/2024 to LPA and to keep daily water log for 2 weeks and submit to LPA to clear citation.
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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Based on observation & interview with Administrator, the licensee did not comply with the section cited above in observing centrally stored medication to be unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator will review regulation 80075(k)(1). Licensee to submit documentation of training, and include date, time, duration, topic, staff names & signatures to CCL attention by POC due date 09/27/2024.
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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/20/2024 07:23 AM - It Cannot Be Edited


Created By: Shannan Hansen On 09/19/2024 at 12:29 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: ZINA'S CARE HOME I
FACILITY NUMBER: 486804110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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 information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in S1 & S2 did not have Health Screening documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator to submit copies of S1 & S2's Health Screening reports to CCL by 9/27/2024 to clear citation.
Type B
Section Cited
CCR
80066(a)(11)
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 information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in S1 & S2 did not have TB tests or results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator to provide copies of S1 & S2 TB tests results by 9/27/2024 to CCL to clear citation.
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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/20/2024 07:23 AM - It Cannot Be Edited


Created By: Shannan Hansen On 09/19/2024 at 12:29 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: ZINA'S CARE HOME I
FACILITY NUMBER: 486804110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review , the licensee did not comply with the section cited above in C1 did not have TB test results, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator to provide copy of C1 TB test result to CCL by PO due date of 9/27/2024 to clear citation. If Administrator needs more time contact LPA and request extension.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed several medications for client (C2) & (C3) that were not properly input on the Centrally Stored Medication Records, which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator indicated that they have scheduled a medication training for all Direct Support Staff on medication administration assistance and recording. Administrator to submit proof of training once completed. In addition, LPA requesting for Administrator and Lead Staff to conduct full medication audit to ensure all client medications are reconciled on Centrally Stored Medication Records. LIC9098 Proof of Corrections form to be submitted to CCL by 9/27/2024
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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


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: ZINA'S CARE HOME I
FACILITY NUMBER: 486804110
VISIT DATE: 09/19/2024
NARRATIVE
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Continued from LIC809:

LPA conducted a spot medication count for clients and found several medications for client (C2 & C3) not properly recorded on the Centrally Stored Medication Record. In addition, LPA found centrally stored medications to be unlocked and accessible to clients in care (see LIC 809-D). Administrator also informed LPA that a medication administration assistance and record keeping training has been scheduled for all staff to complete.

Administrator, Zina Lee's Administrator Certification 6012974735 is currently active until 11/30/2024.

LPA requested the following documents be sent to CCL by COB 10/1/2024:
LIC 308 Designated Facility Responsibility (if changes)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s/Resident’s
LIC 400 Cash Resources
Surety Bond
Control of Property (updated Lease Agreement)


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 Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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