<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804115
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:37:15 PM

Document Has Been Signed on 04/17/2024 12:37 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:PACIFIC GARDENS AT UNIVERSITYFACILITY NUMBER:
486804115
ADMINISTRATOR/
DIRECTOR:		BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:118 UNIVERSITY AVETELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Rowena De VeraTIME VISIT/
INSPECTION COMPLETED:
12:40 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
LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Caregiver Rowena De Vera.

This facility has a fire clearance for six non-ambulatory residents. There is one shared resident room that has a full private bathroom and four private resident rooms. There is one staff room. Backyard was inspected and there is a locked shed in the backyard. LPA reviewed three staff files and three resident files. Common areas and resident rooms were inspected.

The following was observed during today's visit:
-one resident's bed who is not on hospice has full bed rails. Title 22 regulations does not allow full bed rails on a bed unless the resident is on hospice.
-Title 22 regulations requires annual training in multiple subjects. One caregiver has the initial training in 2022, but no training logs other than catheter training in 2023.
-Title 22 regulations requires current first aid for all caregivers on duty. One caregiver's first aid was issued on 07/29/2017. No other card was found since then.
-One caregiver's training was last completed on 04/15/2023. The annual training has not yet been completed for this month.

The following shall be updated and submitted to Community Care Licensing Division by May 1, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule

Deficiencies 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. Appeal rights were provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 3
Document Has Been Signed on 04/17/2024 12:37 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 04/17/2024 at 12:21 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: PACIFIC GARDENS AT UNIVERSITY
FACILITY NUMBER: 486804115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three caregivers does not have current training. The training log found in the caregiver's file was 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
By 05/17/2024, Licensee shall submit a written statement stating how they shall ensure staff have all the required annual training and how it shall be logged.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three caregivers does not have a current first aid card. The caregiver's file had a card that was issued on 07/29/2017 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
By 05/17/2024, Licensee shall submit a written statement stating how they shall ensure all staff have current first aid cards and how they shall keep track of the time.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/17/2024 12:37 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 04/17/2024 at 12:21 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: PACIFIC GARDENS AT UNIVERSITY
FACILITY NUMBER: 486804115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of three caregivers had training completed in 2022, and nothing since which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
By 05/17/2024, Licensee shall submit in writing how they shall ensure staff have required annual training.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one] out of six residents has a full bed rail and is not on hospice which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
By 05/17/2024, Licensee shall submit a written statement on how they shall ensure residents who are not on hospice only have half or quarter bed rails placed as close to the head of the bed as possible.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3